Prescription Drug Guide Comprehensive list of covered drugs

Simply Healthcare Plans, Inc.2013 Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WECOVER IN THIS PLANNote to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,2014.Simply HealthCare Plans, Inc. is a Coordinated Care plan with a Medicare contract and a contract withthe Florida Medicaid program.This information is available for free in other languages. Please contact our Member Services number at1-877-577-0115 for additional information. If you use a TTY device, please call 711. We are open 7days a week, 8 a.m. to 8 p.m. From February 15 th until September 30 th , you may leave us a voice mailmessage after hours, Saturdays, Sundays and holidays, and we will return your call the next businessday.Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestronúmero de atención al afiliado al 1-877-577-0115 para obtener información adicional. Si usted usa undispositivo TTY, por favor llame al 711. El horario de atención es de 8 a.m. a 8 p.m., los siete días de lasemana. A partir del 15 de febrero hasta el 30 de septiembre usted puede dejarnos un mensaje en elcorreo de voz después del horario de trabajo, los sábados, domingos y días festivos y nosotros ledevolveremos la llamada el siguiente día hábil.Formulary ID: 13569 Ver. 13H5471_SHP 2013CForm_BILi

What is the Simply Healthcare Plans, Inc.’s Formulary?A formulary is a list of covered drugs selected by Simply Healthcare Plans, Inc. in consultation with ateam of health care providers, which represents the prescription therapies believed to be a necessary partof a quality treatment program. Simply Healthcare Plans, Inc. will generally cover the drugs listed inour formulary as long as the drug is medically necessary, the prescription is filled at a Simply HealthcarePlans, Inc. network pharmacy, and other plan rules are followed. For more information on how to fillyour prescriptions, please review your Evidence of Coverage.Can the Formulary change?Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when anew, less expensive generic drug becomes available or when new adverse information about the safetyor effectiveness of a drug is released. Other types of formulary changes, such as removing a drug fromour formulary, will not affect members who are currently taking the drug. It will remain available at thesame cost-sharing for those members taking it for the remainder of the coverage year. We feel it isimportant that you have continued access for the remainder of the coverage year to the formulary drugsthat were available when you chose our plan, except for cases in which you can save additional moneyor we can ensure your safety.If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapyrestrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members ofthe change at least 60 days before the change becomes effective, or at the time the member requests arefill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food andDrug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removesthe drug from the market, we will immediately remove the drug from our formulary and provide noticeto members who take the drug. The enclosed formulary is current as of September 1, 2012. To getupdated information about the drugs covered by Simply Healthcare Plans, Inc., please visit our Web siteat www.mysimplymedicare.com or call Member Services at 1-877-577-0115. We are open 7 days aweek, 8 a.m to 8 p.m. From February 15 until the following Annual Election Period (AEP), you mayleave us a voice mail message after-hours, Saturdays, Sundays and holidays and we will return your callthe next business day. TTY/TDD users should call 711. In the event of a mid-year non-maintenanceformulary change such as changing a preferred or non-preferred formulary drug, adding an additionalrequirement or limit to a drug, remove a dosage form, or exchanging therapeutic alternatives by addingor deleting a drug or changing a tier as a result of a therapeutic alternative, we will notify you byproviding you with a written notice of the non-maintenance formulary change.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories dependingon the type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, “Cardiovascular Agents”. If you know what your drug isused for, look for the category name in the list that begins on page number 1. Then look under theii

category name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 53. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand name drugs and generic drugs are listed in the Index. Look in the Index andfind your drug. Next to your drug, you will see the page number where you can find coverageinformation. Turn to the page listed in the Index and find the name of your drug in the first columnof the list.What are generic drugs?Simply Healthcare Plans, Inc. covers both brand name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand name drug. Generally, genericdrugs cost less than brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:Prior Authorization: Simply Healthcare Plans, Inc. requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from SimplyHealthcare Plans, Inc. before you fill your prescriptions. If you don’t get approval, SimplyHealthcare Plans, Inc. may not cover the drug.Quantity Limits: For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drugthat Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to astandard one month or three month supply.Step Therapy: In some cases, Simply Healthcare Plans, Inc. requires you to first try certaindrugs to treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc.may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SimplyHealthcare Plans, Inc. will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. You can also get more information about the restrictions applied to specific covereddrugs by visiting our Web site at www.mysimplymedicare.com.You can ask Simply Healthcare Plans, Inc. to make an exception to these restrictions or limits. See thesection, “How do I request an exception to the Simply Healthcare Plans, Inc.’s formulary?” on page ivfor information about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary, you should first contact Member Services and confirm thatyour drug is not covered. If you learn that Simply Healthcare Plans, Inc. does not cover your drug, youiii

have two options:You can ask Member Services for a list of similar drugs that are covered by Simply HealthcarePlans, Inc. When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Simply Healthcare Plans, Inc.You can ask Simply Healthcare Plans, Inc. to make an exception and cover your drug. See belowfor information about how to request an exception.How do I request an exception to the Simply Healthcare Plans, Inc.’s Formulary?You can ask Simply Healthcare Plans, Inc. to make an exception to our coverage rules. There areseveral types of exceptions that you can ask us to make.You can ask us to cover your drug even if it is not on our formulary.You can ask us to waive coverage restrictions or limits on your drug. For example, for certaindrugs, Simply Healthcare Plans, Inc. limits the amount of the drug that we will cover. If yourdrug has a quantity limit, you can ask us to waive the limit and cover more.You can ask us to provide a higher level of coverage for your drug. If your drug is contained inour non-preferred brand tier, you can ask us to cover it at the cost-sharing amount that applies todrugs in the preferred brand tier instead. This would lower the amount you must pay for yourdrug. Please note, if we grant your request to cover a drug that is not on our formulary, you maynot ask us to provide a higher level of coverage for the drug. “Also, you may not ask us toprovide a higher level of coverage for drugs that are in the Tier 5, Specialty tier.”Generally, Simply Healthcare Plans, Inc. will only approve your request for an exception if thealternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilizationrestrictions would not be as effective in treating your condition and/or would cause you to have adversemedical effects.You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilizationrestriction exception. When you are requesting a formulary, tiering or utilization restrictionexception you should submit a statement from your physician supporting your request. Generally,we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’ssupporting statement. You can request an expedited (fast) exception if you or your doctor believe thatyour health could be seriously harmed by waiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s orprescribing physician’s supporting statement.What do I do before I can talk to my doctor about changing my drugs or requestingan exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,you may be taking a drug that is on our formulary but your ability to get it is limited. For example, youmay need a prior authorization from us before you can fill your prescription. You should talk to yourdoctor to decide if you should switch to an appropriate drug that we cover or request a formularyexception so that we will cover the drug you take. While you talk to your doctor to determine the rightiv

course of action for you, we may cover your drug in certain cases during the first 90 days you are amember of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we willcover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go toa network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you havebeen a member of the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill your prescription until wehave provided you with a 93-day transition supply, consistent with the dispensing increment, (unlessyou have a prescription written for fewer days). We will cover more than one refill of these drugs for thefirst 90 days you are a member of our plan. If you need a drug that is not on our formulary or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while youpursue a formulary exception.For current members who are changing from one treatment setting to another, for example entering along- term care facility from a hospital or being discharged from a hospital to home, the member andprovider will need to utilize our exception and appeals process should the drugs not be on our formulary.Members entering or being discharged from a long-term care facility will be allowed a one-timeemergency supply of a 31-day supply for medications which the member has not already received atransition supply. In addition, the dispensing pharmacist will need to call the Pharmacy Help Desk toreceive appropriate directions to dispense a prescription required due to a level of care change.For more informationFor more detailed information about your Simply Healthcare Plans, Inc. prescription drug coverage,please review your Evidence of Coverage and other plan materials.If you have questions about Simply Healthcare Plans, Inc., please call Member Services at 1-877-577-0115. If you use a TTY device, please call 711. We are open 7 days a week, 8 a.m. to 8 p.m. FromFebruary 15 th until September 30 th , you may leave us a voice mail message after hours, Saturdays,Sundays and holidays, and we will return your call the next business day. Or visitwww.mysimplymedicare.com.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.Simply Healthcare Plans, Inc.’s FormularyThe formulary below provides coverage information about some of the drugs covered by SimplyHealthcarePlans, Inc. If you have trouble finding your drug in the list, turn to the Index that begins on page 53.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR 10MG) and generic drugs are listed in lower-case italics (e.g., pravastatin sodium 10 mg).v

The information in the Requirements/Limits column tells you if Simply Healthcare Plans, Inc. has anyspecial requirements for coverage of your drug.List of AbbreviationsB/DEDGCGC DLAMOPAQLSTThis prescription drug has a Part B versus D administrative prior authorization requirement. Thisdrug may be covered under Medicare Part B or D depending upon the circumstances.Information may need to be submitted describing the use and setting of the drug to make thedetermination.This prescription drug is not normally covered in a Medicare Prescription Drug Plan. Theamount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). Inaddition, if you are receiving extra help to pay for your prescriptions, you will not get any extrahelp to pay for this drug.Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.Please refer to our Evidence of Coverage for more information about this coverage.Additional Gap Coverage for specific plans. We provide additional coverage of this prescriptiondrug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage.Limited Availability. This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.Mail Order Drug. This prescription drug is available through a mail-order service.Prior Authorization. Simply Healthcare Plans, Inc. requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from SimplyHealthcare Plans, Inc. before you fill your prescriptions. If you don't get approval, SimplyHealthcare Plans, Inc. may not cover the drug.Quantity Limit. For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drugthat Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.provides 30 tablets per prescription for Celebrex 100mg Capsules. This may be in addition to astandard one month or three month supply.Step Therapy. In some cases, Simply Healthcare Plans, Inc requires you to first try certain drugsto treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Incmay not cover drug B unless you try Drug A first. If Drug A does not work for you, SimplyHealthcare Plans, Inc will then cover Drug.vi

FormularyDrug TierFormulary DrugLabel NameCopayment/Co-insuranceat Retail and Mail OrderPharmacies1 Preferred Generic Lowest Copayment2 Non-Preferred Generic Low Copayment3 Preferred Brand Medium Copayment4 Non-Preferred Brand High CopaymentExplanationCopayment for a 30-daysupply retail or 90-daysupply mail-order/ perprescription or refill.Copayment for a 30-daysupply retail or 90-daysupply mail-order/ perprescription or refill.Copayment for a 30-daysupply retail or 90-daysupply mail-order/ perprescription or refill.Copayment for a 30-daysupply retail/ perprescription or refill.5 Specialty Tier High Co-InsuranceCoinsurance for a 30-daysupply retail/ perprescription or refill.Note: Please see your Evidence of Coverage for specific cost sharing amounts and for theavailability of 90-Day Retail & Mail-Order supplies for Tier 1-3. Members getting Extra Help willpay their Low Income Subsidy (LIS) copayment. Please refer to your LIS rider or call MemberServices at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. If you use a TTY device,please call 711.vii

Simply Healthcare Plans, Inc.Formulario de 2013(Lista de medicamentos cubiertos)LEA POR FAVOR: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOSMEDICAMENTOS QUE CUBRE ESTE PLANNota a los afiliados existentes: Este formulario ha cambiado desde el año pasado. Revise estedocumento para asegurarse de que sigue incluyendo los medicamentos que toma.Los beneficiarios deben usar las farmacias de la red para tener acceso a su beneficio de medicamentosrecetados. El 1 de enero de 2014 podría haber cambios en los beneficios, el formulario, la red defarmacias, las primas, los copagos o el coaseguro.Simply HealthCare Plans, Inc. es un Plan de cuidados coordinados con un contrato Medicare Advantagey un contrato con el programa de Medicaid de la Florida.This information is available for free in other languages. Please contact our member service number at1-877-577-0115 for additional information. If you use a TTY device, please call 711. We are open 7days a week, 8 a.m. to 8 p.m. From February 15 th until September 30 th , you may leave us a voice mailmessage after hours, Saturdays, Sundays and holidays, and we will return your call the next businessday.Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestronúmero de atención al afiliado al 1-877-577-0115 para obtener información adicional. Si usted usa undispositivo TTY, por favor llame al 711. El horario de atención es de 8 a.m. a 8 p.m., los siete días de lasemana. A partir del 15 de febrero hasta el 30 de septiembre usted puede dejarnos un mensaje en elcorreo de voz después del horario de trabajo, los sábados, domingos y días festivos y nosotros ledevolveremos la llamada el siguiente día hábil.viii

¿Qué es el Formulario de Simply Healthcare Plans, Inc.?El formulario es una lista de medicamentos seleccionados cubiertos por Simply Healthcare Plans, Inc. encolaboración con un equipo de proveedores de atención médica, que representa las terapiasfarmacológicas consideradas como parte necesaria de un programa de tratamiento de calidad. Por logeneral, Simply Healthcare Plans, Inc. cubrirá los medicamentos incluidos en nuestro formulariosiempre y cuando se necesiten por razones médicas, el medicamento sea surtido en una farmacia de lared de Simply Healthcare Plans, Inc., y se hayan seguido otras reglas de cobertura. Si desea másinformación sobre cómo hacer para que le surtan sus medicamentos recetados, consulte su Evidencia deCobertura.¿Es posible que cambie el formulario?Por lo general, si está tomando un medicamento de nuestro formulario del 2013 que estaba cubierto alprincipio del año, no lo descontinuaremos ni reduciremos su cobertura durante el año de cobertura 2013,excepto cuando un medicamento genérico nuevo y menos costoso se ponga a disposición, o cuando sepublique nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos decambios en el formulario, como el retiro de un medicamento de nuestro formulario, no afectará a losafiliados que están tomando actualmente el medicamento. Seguirá estando disponible con la mismaparticipación de costos para aquellos afiliados que lo están tomando durante el resto del año decobertura. Creemos que es importante que usted tenga acceso continuo durante el resto del año de lacobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan,excepto en los casos en los que pueda ahorrar dinero o podamos garantizar su seguridad.Si retiramos medicamentos de nuestro formulario o añadimos autorizaciones previas, límites en lascantidades o restricciones en la terapia por fases en un medicamento, o trasladamos un medicamento aun nivel con distribución de costos más alta, debemos notificar a los afiliados afectados sobre el cambiocuando menos con 60 días de anticipación a que entre en vigencia. Alternativamente, daremosnotificación cuando el afiliado solicite la repetición de la receta del medicamento, momento en el cual elafiliado recibirá un surtido de 60 días del medicamento en cuestión. Si la Administración de Alimentosy Medicamentos considera que un medicamento en nuestro formulario no es seguro, o el fabricante delmedicamento lo retira del mercado, nosotros eliminaremos inmediatamente dicho medicamento denuestro formulario y daremos aviso a los afiliados que lo usan. El formulario adjunto fue actualizado el1 de Septiembre del 2012. Si desea información actualizada de los medicamentos cubiertos por SimplyHealthcare Plans, Inc., visite nuestro sitio web en www.mysimplymedicare.com o comuníquese con elDepartamento de Servicios para Afiliados llamando al 1-877-577-0115. Estamos disponibles los 7 díasde la semana de 8 a.m. a 8 p.m. a partir del 15 de Febrero hasta el próximo periodo Anual de Elecciones(AEP por sus siglas en Ingles) puede dejarnos un mensaje de voz después del horario de trabajo, lossábados, domingos y días festivos y le devolveremos la llamada al siguiente día hábil. Los usuarios conTTY/TDD deben marcar 711. En caso de que se haga un cambio en el formulario de un medicamentoque no sea de mantenimiento a mitad de año, como el cambio de un medicamento preferido o nopreferido del formulario, añadir un requisito adicional o poner un límite a un medicamento, retirar unaforma de dosis, o intercambiar alternativas terapéuticas agregando o eliminando un medicamento ocambiando un nivel como resultado de una alternativa terapéutica, se lo notificaremos mediante avisopor escrito del cambio en el formulario del medicamento que no es de mantenimiento.ix

¿Cómo uso el formulario?Hay dos maneras de encontrar su medicamento en el formulario.AfecciónEl formulario comienza en la página 1. Los medicamentos en este formulario se agrupan encategorías en función del tipo de afecciones que tratan habitualmente. Por ejemplo, losmedicamentos para tratar afecciones cardiacas se incluyen en la categoría “AgentesCardiovasculares”. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en lalista que comienza en la página 1. A continuación busque su medicamento en dicha categoría.Lista en orden alfabéticoSi no sabe a qué categoría corresponde su medicamento, deberá buscarlo en el Índice que comienzaen la página 53. El Índice ofrece una lista alfabética de todos los medicamentos incluidos en estedocumento. El Índice incluye tanto los medicamentos de marca como los genéricos. Busque en elÍndice para encontrar su medicamento. Junto al medicamento, verá el número de la página quecontiene la información sobre la cobertura. Vaya a la página indicada en el Índice y encuentre elnombre de su medicamento en la primera columna de la lista.¿Qué son los medicamentos genéricos?Simply Healthcare Plans, Inc. cubre medicamentos genéricos y de marca. Un medicamento genéricorecibirá la aprobación de la FDA si tiene el mismo ingrediente activo que el medicamento de marca. Porlo general, los medicamentos genéricos cuestan menos que los de marca.¿Hay restricciones en mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura.Estos requisitos y límites pueden incluir:Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtenganautorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobaciónde Simply Healthcare Plans, Inc. antes de que pueda surtir sus recetas. Si no obtiene laaprobación, es posible que Simply Healthcare Plans, Inc. no cubra el medicamento.Límites en la Cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. limita lacantidad del medicamento que Simply Healthcare Plans, Inc. va a cubrir. Por ejemplo, SimplyHealthcare Plans, Inc. proporciona 30 tabletas por receta del medicamento LIPITOR ENTABLETAS DE 10 MG. Esto puede ser adicional al suministro estándar de un mes o tresmeses.Terapia por Fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebeprimero ciertos medicamentos para tratar su condición médica antes de que demos cobertura aotro medicamento para dicha afección. Por ejemplo, si tanto el Medicamento A como elMedicamento B tratan su condición médica, es posible que Simply Healthcare Plans, Inc. nocubra el Medicamento B a menos que usted pruebe primero el Medicamento A. Si elMedicamento A no funciona en su caso, Simply Healthcare Plans, Inc. cubrirá el MedicamentoB.x

Usted puede consultar el formulario que comienza en la página 1 para determinar si su medicamentotiene requisitos o límites adicionales. También puede obtener más información sobre las restriccionesque se aplican a medicamentos cubiertos específicos si visita nuestro sitio web enwww.mysimplymedicare.com.Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o límites.Consulte la sección “¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?”en la pagina xi obtener información sobre cómo solicitar una excepción.¿Qué sucede si su medicamento no está en el formulario?Si su medicamento no está incluido en esta lista, debe comunicarse primero con el Departamento deServicios para Afiliados para confirmar que no está cubierto. Si se entera de que Simply HealthcarePlans, Inc. no cubre su medicamento, usted tiene dos opciones:Puede comunicarse con el Departamento de Servicios para Afiliados para solicitar una lista delos medicamentos similares que cubre Simply Healthcare Plans, Inc. Cuando la reciba,muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto porSimply Healthcare Plans, Inc.Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones olímites. Consulte la sección que sigue para obtener información sobre cómo solicitar unaexcepción.¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a nuestras reglas de cobertura.Hay varios tipos de excepciones que puede pedir.Puede solicitarnos que cubramos su medicamento aunque no esté incluido en nuestroformulario.Puede solicitarnos que cancelemos las restricciones o limitaciones en la cobertura para sumedicamento. Por ejemplo, en algunos medicamentos, Simply Healthcare Plans, Inc. limita lacantidad que tendrá cobertura. Si su medicamento tiene un límite en la cantidad, puedesolicitarnos que cancelemos dicha limitación y cubramos una mayor cantidad.Puede pedirnos que proporcionemos un nivel de cobertura más alto para su medicamento. Si sumedicamento está incluido en nuestro nivel de medicamentos de marca no preferidos, puedesolicitarnos que en su lugar lo cubramos en el nivel de participación de costos que se aplica a losmedicamentos que están en el nivel de medicamentos de marca preferidos. Esto reduciría lacantidad que debe pagar por el medicamento. Tenga presente que si concedemos la solicitud decubrir un medicamento que no se incluye en nuestro formulario, usted no puede pedirnos quedemos un nivel de cobertura más alto para dicho medicamento. “Asimismo, no puede pedirnosque demos un nivel de cobertura más alto a los medicamentos que están en el Nivel 5, quecorresponde a los medicamentos especiales.”Por lo general, Simply Healthcare Plans, Inc. solo aprobará su solicitud para una excepción si losmedicamentos alternativos incluidos en el formulario del plan, o el medicamento de nivel más bajo o lasxi

estricciones de uso adicional no son tan eficaces para tratar su afección o pueden ocasionar efectosmédicos adversos.Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción en elformulario, el nivel o la limitación en el uso. Cuando solicite una excepción en el formulario, el nivelo la limitación en el uso, debe presentar una declaración de su médico que respalde su solicitud.Por lo general, debemos tomar una decisión en un plazo de 72 horas a partir del momento en el quehayamos recibido la declaración de respaldo de su médico tratante o de quien le receta. Usted puedesolicitar una excepción acelerada (rápida) si su médico considera que una espera de 72 horas para unadecisión puede perjudicar gravemente su salud. Si se concede acelerar su solicitud, debemos otorgarleuna decisión antes de 24 horas a partir del momento en que recibamos la declaración de respaldo de sumédico tratante o de quien le receta.¿Qué debo hacer antes de hablar con mi médico sobre el cambio de mismedicamentos o la solicitud de una excepción?Si usted es afiliado nuevo o continúa en nuestro plan, podría estar tomando medicamentos que no estánen nuestro formulario. O podría estar tomando un medicamento que está en nuestro formulario pero sucapacidad para adquirirlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestraparte para poder surtir su receta. Debe hablar con su médico para decidir si debe cambiar a unmedicamento apropiado que nosotros cubramos o solicitar una excepción en el formulario para quepodamos cubrir el medicamento que está tomando. Mientras habla con su médico para determinar elmejor modo de actuar para usted, podríamos cubrir su medicamento en ciertos casos durante losprimeros 90 días de su afiliación a nuestro plan.Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para adquirirsus medicamentos es limitada, daremos cobertura a un suministro temporal de 30 días (a menos quetenga una receta para un número menor de días) cuando vaya a una farmacia de la red. Después de suprimer suministro de 30 días, nosotros no pagaremos estos medicamentos, incluso si usted ha estadoafiliado al plan menos de 90 días.Si reside en un establecimiento de atención médica prolongada, le permitiremos que surta su receta hastaque hayamos proporcionado un suministro de transición de 93 días, consistente con el incremento en elsuministro, (a menos que su receta indique un número menor de días). Daremos cobertura a más de unsurtido de estos medicamentos durante los primeros 90 días de su afiliación a nuestro plan. Si necesitaun medicamento que no está en nuestro formulario, o si su capacidad para adquirir sus medicamentos eslimitada, pero han pasado los primeros 90 días de su afiliación a nuestro plan, daremos cobertura a unsuministro de emergencia de 31 días de dicho medicamento (a menos que su receta indique un númeromenor de días) mientras busca una excepción en el formulario.Para los afiliados actuales que están cambiando de un lugar de tratamiento a otro, por ejemplo, sidespués de estar en un hospital ingresan a un establecimiento de atención médica prolongada, o queregresan a su hogar después de ser dados de alta de un hospital, el afiliado y el proveedor deberánutilizar nuestro proceso de excepciones y apelaciones en caso de que los medicamentos no estén ennuestro formulario. Los afiliados que ingresan a un establecimiento de atención médica prolongada, oque salen de él, tendrán permitido un suministro único de emergencia de 31 días de los medicamentospara los cuales no hayan recibido aún un suministro de transición. Adicionalmente, el farmacéutico quesurte la receta deberá comunicarse con el Centro de Ayuda para Farmacias con el fin de recibirinstrucciones apropiadas para surtir una receta requerida debido a un cambio en el nivel de la atención.xii

Si desea más informaciónSi desea información detallada sobre su cobertura de medicamentos recetados de Simply HealthcarePlans, Inc., consulte su Evidencia de Cobertura y demás documentos del plan.Si tiene preguntas sobre Simply Healthcare Plans, Inc., comuníquese con el Departamento de Serviciospara Afiliados llamando al 1-877-577-0115. Los usuarios con TTY/TDD deben marcar 711. Estamosdisponibles los 7 días de la semana de 8 a.m. a 8 p.m. a partir del 15 de Febrero hasta el 30 deseptiembre puede dejarnos un mensaje de voz después del horario de trabajo, los sábados, domingos ydías festivos y devolveremos la llamada al siguiente día hábil. O visite www.mysimplymedicare.com.Si tiene alguna pregunta general sobre la cobertura de medicamentos recetados de Medicare,comuníquese con Medicare llamando al 1-800-MEDICARE (1-800-633-4227). Se atiende las 24 horasdel día, los 7 días de la semana. Las personas con impedimentos auditivos pueden llamar al 1-877-486-2048 o visitar la página www.medicare.gov.Formulario de Simply Healthcare Plans, Inc.El formulario que se ofrece a continuación proporciona información de cobertura de algunos de losmedicamentos cubiertos por Simply Healthcare Plans, Inc. Si tiene problemas para encontrar sumedicamento en la lista, diríjase al Índice que comienza en la página 53.En la primera columna del diagrama se incluye el nombre del medicamento. Los medicamentos demarca están con letras mayúsculas (por ejemplo, LIPITOR 10 MG), y los medicamentos genéricos seincluyen con letras minúsculas en itálica (por ejemplo, pravastatin sodium 10 mg).La información en la columna de requisitos y límites indica si Simply Healthcare Plans, Inc. tiene algúnrequisito especial para dar cobertura a su medicamento.Listado De AbreviacionesB/DEDGCGC DAutorización Previa B v D. Dependiendo de las circunstancias, este medicamento podría tenercobertura bajo la Parte B o la Parte D de Medicare. Puede ser necesario enviar informaciónsobre el uso del medicamento y la situación específica para tomar una determinación.Este medicamento recetado por lo general no está cubierto en un Plan de MedicamentosRecetados de Medicare. La cantidad que usted paga cuando le surten una receta de estemedicamento no se toma en cuenta en su costo total de medicamentos (es decir, la cantidad quepaga no le ayuda a reunir los requisitos para la cobertura por catástrofe). Además, si estárecibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar por este medicamento.Cobertura adicional. Proporcionamos cobertura adicional de este medicamento recetado durantela brecha en la cobertura. Consulte nuestra Evidencia de Cobertura para obtener másinformación sobre esta cobertura.Cobertura adicional durante la brecha para ciertos planes. Proporcionamos cobertura adicionalde este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia dexiii

Cobertura para obtener más información sobre esta cobertura.LAMOPAQLSTDisposición Limitada. Este medicamento recetado solo podría estar disponible en algunasfarmacias. Si desea más información, consulte su Directorio de proveedores/Farmacias ocomuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Seatiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711.Este medicamento recetado puede obtenerse mediante pedido por correo.Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtengaautorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener laaprobación de Simply Healthcare Plans, Inc. antes de adquirir su medicamento. Si no obtieneaprobación, Simply Healthcare Plans, Inc. podría no cubrir el medicamento.Límites en la cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. establecelímites en las cantidades que cubre. Por ejemplo, Simply Healthcare Plans, Inc. proporciona 30tabletas por receta del medicamento Celebrex en capsulas de 100mg. Esto puede ser adicional alsuministro estándar de un mes o tres meses.Terapia por fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebeprimero ciertos medicamentos para el tratamiento de su condición médica antes que cubramosotros medicamentos indicados para ese tratamiento. Por ejemplo, si los medicamentos A y Bestán indicados para el tratamiento de su condición médica, es posible que Simply HealthcarePlans, Inc. no cubra el medicamento B si usted no prueba primero el medicamento A. Si elmedicamento A no es efectivo, entonces Simply Healthcare Plans, Inc. cubrirá el medicamentoB.xiv

Nivel delMedicamentoen elFormularioNombre del Nivel enel FormularioCopago/Coaseguro enFarmacias Minoristas yFarmacias con Pedidospor Correo1 Genérico Preferido Copago mas bajo2 Genérico No-Preferido Copago bajo345Medicamento de MarcaPreferidoMedicamento de MarcaNo- PreferidoMedicamentosespecialesCopago MedianoAlto CopagoAlto CoaseguroExplicaciónCopago por un suministrode 30 días por receta orelleno en farmaciasminoristas o copago por unsuministro de 90 días porreceta o relleno para pedidopor correo.Copago por un suministrode 30 días por receta orelleno en farmaciasminoristas o copago por unsuministro de 90 días porreceta o relleno para pedidopor correo.Copago por un suministrode 30 días por receta orelleno en farmaciasminoristas o copago por unsuministro de 90 días porreceta o relleno para pedidopor correo.Copago por un suministrode 30 días por receta orelleno en farmaciasminoristas.Coaseguro por unsuministro de 30 días porreceta o relleno enfarmacias minoristas.Nota: Por favor consulte nuestra Evidencia de Cobertura para obtener más información sobre suscopagos y la disponibilidad de un suministro de 90 días en farmacias minoristas y pedidos por correode medicamentos en los Niveles 1-3. Afiliados recibiendo ayuda adicional pagaran el copagoestablecido en la Clausula para el subsidio por ingreso limitado. Por favor refiérase a su Clausulapara el subsidio por ingreso limitado o llame a nuestro Departamento de Servicios para el afiliado al1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY deben marcar 711.xv

Drug NameDrugTier Requirements/Limitsoxycodone/acetaminophen tabs 325mg, 10mg, 325mg, 2.5mg, 2 QL (360 EA per 30 days) MO GC325mg, 7.5mgoxycodone/aspirin 1 MO GCpentazocine/acetaminophen 1 QL (180 EA per 30 days) PA MOGCpentazocine/naloxone hcl 1 MO GCreprexain 1 MO GCROXICET 3 QL (1800 ML per 30 days) MOstagesic 1 QL (240 EA per 30 days) MO GCSYNALGOS-DC 4tramadol hydrochloride/acetaminophen 1 QL (240 EA per 30 days) MO GCNonsteroidal Anti-inflammatory DrugsCELEBREX CAPS 100MG 4 QL (30 EA per 30 days) STCELEBREX CAPS 200MG, 400MG, 50MG 4 QL (60 EA per 30 days) STdiclofenac potassium 1 MO GCdiclofenac sodium dr 1 MO GCdiclofenac sodium er 1 MO GCdiclofenac sodium/misoprostol 2 MO GCdiflunisal 1 MO GCetodolac er 2 MO GCetodolac caps 200mg 1 MO GCetodolac tabs 1 MO GCfenoprofen calcium 1 MO GCFLECTOR 4flurbiprofen 1 MO GCibuprofen susp 1 MO GCibuprofen tabs 400mg, 600mg, 800mg 1 MO GCINDOCIN SUSP 4indomethacin er 1 MO GCindomethacin caps 1 MO GCketoprofen 1 MO GCketoprofen er 2 MO GCketorolac tromethamine tabs 1 QL (20 EA per 30 days) PA MO GCketorolac tromethamine inj 15mg/ml, 30mg/ml 1 QL (20 ML per 30 days) PA MO GCMECLOFENAMATE SODIUM CAPS 50MG 4meclofenamate sodium caps 100mg 2 MO GCmefenamic acid 2 MO GCmeloxicam tabs 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 2 of 73

Drug NameDrugTier Requirements/Limitsmeloxicam susp 2 MO GCnabumetone 1 MO GCnaproxen 1 MO GCnaproxen dr 1 MO GCnaproxen sodium tabs 275mg, 550mg 1 MO GCoxaprozin 1 MO GCoxycodone/ibuprofen 2 MO GCPENNSAID 4piroxicam 1 MO GCsulindac 1 MO GCtolmetin sodium 2 MO GCOpioid Analgesics, Long-actingABSTRAL SUBL 100MCG 4 QL (120 EA per 30 days) ST PAABSTRAL SUBL 200MCG, 800MCG 5 QL (120 EA per 30 days) ST PAastramorph 1 MO GCEXALGO TB24 12MG, 8MG 4 QL (60 EA per 30 days)EXALGO TB24 16MG 5 QL (120 EA per 30 days)FENTANYL CITRATE ORAL TRANSMUCOSAL 5 QL (120 EA per 30 days) PAfentanyl pt72 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 100mcg/hr 2 QL (30 EA per 30 days) MO GCFENTORA 5 QL (120 EA per 30 days) ST PAmethadone hcl tabs 1 MO GCmethadone hcl soln 5mg/5ml 1 MO GCmorphine sulfate er tb12 1 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 2 QL (60 EA per 30 days) MO GCmorphine sulfate soln, tabs 1 MO GCMS CONTIN TB12 100MG, 15MG, 30MG, 60MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 50MG 4 QL (300 EA per 30 days)NUCYNTA ER TB12 100MG, 150MG, 200MG, 250MG 4 QL (60 EA per 30 days)ONSOLIS FILM 200MCG 5 QL (120 EA per 30 days) ST PAONSOLIS FILM 400MCG 5 QL (90 EA per 30 days) ST PAOPANA ER (CRUSH RESISTANT) TB12 10MG, 20MG, 3 QL (60 EA per 30 days) MO30MG, 5MGOPANA ER (CRUSH RESISTANT) TB12 40MG 5 QL (60 EA per 30 days)OXYCONTIN TB12 10MG, 15MG, 20MG, 30MG, 40MG, 4 QL (60 EA per 30 days)60MGOXYCONTIN TB12 80MG 5 QL (120 EA per 30 days)oxymorphone hydrochloride er tb12 15mg 2 QL (60 EA per 30 days) MO GCtramadol hcl er tb24 2 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 3 of 73

Drug NameDrugTier Requirements/LimitsOpioid Analgesics, Short-actingbutorphanol tartrate nasal soln 2 MO GCbutorphanol tartrate inj 2mg/ml 2 MO GCCODEINE SULFATE TABS 60MG 3 MOcodeine sulfate tabs 30mg 2 MO GCDILAUDID-5 4hydromorphone hcl tabs 1 MO GChydromorphone hcl inj 500mg/50ml 1 MO GCmeperidine hcl inj 100mg/ml, 25mg/ml, 50mg/ml 2 PA MO GCmeperitab 2 PA MO GCnalbuphine hcl 1 MO GCNUCYNTA 4 QL (180 EA per 30 days)oxycodone hcl soln 1 MO GCoxycodone hcl caps 1 MO GCoxycodone hcl conc 2 MO GCoxycodone hcl tabs 10mg, 20mg 1 MO GCoxycodone hcl tabs 15mg, 30mg, 5mg 1 MO GCoxymorphone hydrochloride 2 MO GCtramadol hcl 1 MO GCAnestheticsLocal Anestheticslidocaine hcl jelly 1 MO GClidocaine hcl external soln 1 MO GClidocaine hcl inj 1% 1 MO GClidocaine viscous 1 MO GClidocaine/prilocaine crea 2 B/D MO GClidocaine oint 1 B/D MO GCLIDODERM 4Anti-Addiction/ Substance Abuse Treatment AgentsAlcohol Deterrents/ Anti-cravingCAMPRAL 4disulfiram 2 MO GCnaltrexone hcl 2 MO GCAnti-Addiction/ Substance Abuse Treatment AgentsSUBOXONE 4 QL (90 EA per 30 days)Opioid Antagonistsbuprenorphine hcl 2 MO GCnaloxone hcl 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 4 of 73

Drug NameDrugTier Requirements/LimitsSUBOXONE FILM 4MG, 1MG 5 QL (180 EA per 30 days)SUBOXONE FILM 12MG, 3MG 5 QL (90 EA per 30 days)Smoking Cessation AgentsCHANTIX STARTING MONTH PAK 4 QL (53 EA per 28 days) PACHANTIX TABS 1MG 4 QL (56 EA per 30 days) PACHANTIX TABS 0.5MG 4 QL (60 EA per 30 days) PANICOTROL NS 3 MOAnti-inflammatory AgentsNonsteroidal Anti-inflammatory Drugsnaproxen 1 MO GCAntibacterialsAminoglycosidesamikacin sulfate inj 1gm/4ml 1 MO GCgentak oint 1 MO GCgentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml, 0.9%, 1 MO GC1mg/ml, 0.9%gentamicin sulfate crea, inj, oint, ophthalmic soln 1 MO GCisotonic gentamicin inj 0.8mg/ml, 0.9% 1 MO GCKANAMYCIN SULFATE 4neomycin sulfate 1 MO GCparomomycin sulfate 1 MO GCTOBI 4TOBRADEX OINT 4tobramycin sulfate ophthalmic soln 1 MO GCtobramycin sulfate inj 10mg/ml, 80mg/2ml 1 MO GCTOBREX OINT 4Antibacterials, Otheracetic acid 1 MO GCalcohol preps pads 1 MO GCALTABAX 4bacitracin oint 2 MO GCBACTROBAN NASAL 4BACTROBAN CREA 4CLEOCIN PEDIATRIC GRANULES 4CLEOCIN SUPP 4clindamycin hcl caps 150mg, 300mg 1 MO GCclindamycin phosphate add-vantage 1 MO GCclindamycin phosphate crea, gel, lotn, soln, swab 1 MO GCclindamycin phosphate foam 2 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 5 of 73

Drug NameDrugTier Requirements/LimitsCUBICIN 5LINCOCIN 3 MOMACRODANTIN CAPS 25MG 4 PAmethenamine hippurate 2 MO GCMETROGEL 4metronidazole in nacl 0.79% 2 MO GCmetronidazole vaginal 1 MO GCmetronidazole crea, gel, lotn, tabs 1 MO GCmetronidazole caps 2 MO GCMONUROL 4mupirocin oint 1 MO GCNITROFURANTOIN 4nitrofurantoin macrocrystalline caps 50mg 2 PA MO GCnitrofurantoin monohydrate 2 PA MO GCSULFAMYLON CREA 4trimethoprim 1 MO GCTYGACIL 4VANCOMYCIN HCL CAPS 5vancomycin hcl inj 1000mg, 10gm, 500mg 2 B/D MO GCvandazole 1 MO GCXIFAXAN TABS 200MG 4 QL (9 EA per 30 days)XIFAXAN TABS 550MG 5 QL (60 EA per 30 days)ZYVOX INJ 5 PAZYVOX SUSR 5 QL (1800 ML per 30 days) PAZYVOX TABS 5 QL (56 EA per 30 days) PAAntibacterialsCOLISTIMETHATE SODIUM 4 B/DSYNERCID 5Beta-lactam, Cephalosporinscefaclor caps 1 MO GCcefadroxil 2 MO GCcefazolin sodium inj 10gm, 1gm, 500mg 2 MO GCcefdinir 2 MO GCcefepime inj 1gm, 2gm 2 MO GCcefotaxime sodium inj 10gm, 1gm, 2gm 2 MO GCcefotetan 2 MO GCcefoxitin sodium inj 1gm, 4%, 2gm 2 MO GCcefpodoxime proxetil 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 6 of 73

Drug NameDrugTier Requirements/Limitscefprozil 2 MO GCceftazidime inj 1gm, 2gm 2 MO GCceftriaxone sodium inj 10gm, 250mg, 500mg 2 MO GCcefuroxime axetil tabs 2 MO GCcefuroxime sodium inj 1.5gm, 7.5gm, 750mg 2 MO GCcephalexin caps, susr 1 MO GCSPECTRACEF TABS 400MG 4SUPRAX CHEW, TABS 4SUPRAX SUSR 100MG/5ML 4TEFLARO INJ 400MG 4 B/DBeta-lactam, Otheraztreonam inj 1gm 2 MO GCCAYSTON 5 QL (84 ML per 28 days) PADORIBAX INJ 500MG 4imipenem/cilastatin 2 MO GCINVANZ 4meropenem inj 500mg 2 MO GCBeta-lactam, Penicillinsamoxicillin/clavulanate potassium er 2 MO GCamoxicillin/clavulanate potassium chew 2 MO GCamoxicillin/clavulanate potassium susr 250mg/5ml,2 MO GC62.5mg/5ml, 400mg/5ml, 57mg/5ml, 600mg/5ml, 42.9mg/5mlamoxicillin/clavulanate potassium tabs 250mg, 125mg 2 MO GCamoxicillin/potassium clavulanate tabs 2 MO GCamoxicillin/potassium clavulanate susr 200mg/5ml,2 MO GC28.5mg/5mlamoxicillin chew 250mg 1 MO GCamoxicillin caps, susr, tabs 1 MO GCampicillin sodium inj 125mg, 1gm 1 MO GCampicillin-sulbactam inj 10gm, 5gm, 2gm, 1gm 2 MO GCampicillin caps 1 MO GCBICILLIN C-R INJ 300000UNIT/ML, 300000UNIT/ML 4BICILLIN L-A 4dicloxacillin sodium 1 MO GCnafcillin sodium inj 1gm 1 MO GCPENICILLIN G POTASSIUM IN ISO-OSMOTIC3 MODEXTROSE INJ 0, 60000UNIT/MLpenicillin g potassium inj 5mu 1 MO GCpenicillin g sodium 1 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 7 of 73

Drug NameDrugTier Requirements/Limitspenicillin v potassium 1 MO GCpiperacillin sodium/tazobactam sodium inj 3gm, 0.375gm 2 MO GCMacrolidesAKNE-MYCIN 4AZASITE 4azithromycin susr, tabs 2 MO GCazithromycin inj 500mg 2 MO GCclarithromycin 2 MO GCclarithromycin er 2 MO GCDIFICID 4 PAE.E.S. 400 3 MOE.E.S. GRANULES 3 MOery 2 MO GCERY-TAB 4ERYPED 200 4ERYPED 400 4ERYTHROCIN STEARATE 3 MOerythromycin ethylsuccinate 1 MO GCerythromycin gel, oint, soln 1 MO GCZITHROMAX PACK 4QuinolonesAVELOX 4BESIVANCE 4CILOXAN OINT 4ciprofloxacin er 2 MO GCciprofloxacin hcl 1 MO GCciprofloxacin inj 400mg/40ml 2 MO GCCIPRO SUSR 500MG/5ML 4FACTIVE 4levofloxacin 1 MO GClevofloxacin in d5w inj 5%, 500mg/100ml 1 MO GCMOXEZA 4ofloxacin ophthalmic soln, otic soln 1 MO GCofloxacin tabs 2 MO GCVIGAMOX 4ZYMAXID 4Sulfonamidessilver sulfadiazine 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 8 of 73

Drug NameDrugTier Requirements/Limitssodium sulfacetamide 1 MO GCSSD 3 MOsulfacetamide sodium susp 2 MO GCsulfadiazine 1 MO GCsulfamethoxazole/trimethoprim 1 MO GCsulfamethoxazole/trimethoprim ds 1 MO GCTHERMAZENE 3 MOTetracyclinesDEMECLOCYCLINE HCL 4doxycycline hyclate caps 1 MO GCdoxycycline hyclate inj 2 MO GCdoxycycline hyclate tabs 100mg 1 MO GCdoxycycline hyclate tabs 20mg 2 MO GCdoxycycline hyclate tbec 150mg 2 MO GCdoxycycline monohydrate tabs 150mg, 50mg 2 MO GCdoxycycline caps 75mg 2 MO GCminocycline hcl caps 1 MO GCtetracycline hcl 1 MO GCAnticonvulsantsAnticonvulsants, Otherlevetiracetam er 2 MO GClevetiracetam oral soln, tabs 1 MO GClevetiracetam inj 500mg/5ml 2 MO GCONFI 4 QL (60 EA per 30 days)phenobarbital elix 1 QL (1500 ML per 30 days) PA MOGCphenobarbital tabs 32.4mg 1 QL (30 EA per 30 days) PA MO GCphenobarbital tabs 100mg, 15mg, 60mg 1 QL (90 EA per 30 days) PA MO GCphenobarbital tabs 16.2mg, 30mg, 64.8mg, 97.2mg 1 QL (90 EA per 30 days) PA MO GCPOTIGA 5 PACalcium Channel Modifying AgentsCELONTIN 4ethosuximide 2 MO GCLYRICA SOLN 3 QL (450 ML per 30 days) MOLYRICA CAPS 225MG, 300MG 3 QL (60 EA per 30 days) MOLYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 3 QL (90 EA per 30 days) MO75MGzonisamide 1 MO GCGamma-aminobutyric Acid (GABA) Augmenting AgentsPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 9 of 73

Drug NameDrugTier Requirements/Limitsdivalproex sodium 1 MO GCdivalproex sodium dr 1 MO GCdivalproex sodium er 1 MO GCgabapentin 1 MO GCGABITRIL TABS 12MG 4 QL (120 EA per 30 days)GABITRIL TABS 2MG 4 QL (30 EA per 30 days)GABITRIL TABS 16MG, 4MG 4 QL (60 EA per 30 days)primidone 1 MO GCSABRIL TABS 4 QL (180 EA per 30 days) LASABRIL PACK 5 QL (180 EA per 30 days)STAVZOR CPDR 500MG 4tiagabine hydrochloride 2 QL (60 EA per 30 days) MOvalproate sodium 1 MO GCvalproic acid 1 MO GCGlutamate Reducing Agentsfelbamate 2 MO GCLAMICTAL ODT TBDP 200MG 4 QL (30 EA per 30 days)LAMICTAL ODT TBDP 100MG, 25MG 4 QL (60 EA per 30 days)LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 4 QL (49 EA per 30 days)LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT 4 QL (98 EA per 30 days)TAKING VALPROATELAMICTAL STARTER/TAKING VALPROATE 4 QL (35 EA per 30 days)LAMICTAL XR KIT 0 4 QL (35 EA per 35 days)LAMICTAL XR TB24 250MG 4 QL (30 EA per 30 days)LAMICTAL XR TB24 100MG, 25MG, 50MG 4 QL (60 EA per 30 days)LAMICTAL XR TB24 200MG 4 QL (90 EA per 30 days)lamotrigine 1 MO GClamotrigine er tb24 250mg, 300mg 2 QL (30 EA per 30 days) MO GClamotrigine er tb24 100mg, 25mg, 50mg 2 QL (60 EA per 30 days) MO GClamotrigine er tb24 200mg 2 QL (90 EA per 30 days) MO GCtopiramate 1 MO GCSodium Channel AgentsBANZEL SUSP 5 QL (2400 ML per 30 days)BANZEL TABS 200MG 4 QL (60 EA per 30 days)BANZEL TABS 400MG 5 QL (240 EA per 30 days)carbamazepine er 2 MO GCcarbamazepine chew, susp 1 MO GCDILANTIN 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 10 of 73

Drug NameDrugTier Requirements/LimitsDILANTIN INFATABS 4epitol 1 MO GCEQUETRO CP12 100MG, 300MG 4EQUETRO CP12 200MG 4 QL (240 EA per 30 days)oxcarbazepine tabs 1 MO GCPEGANONE 4PHENYTEK 4phenytoin sodium extended 1 MO GCphenytoin susp 1 MO GCphenytoin chew 2 MOTEGRETOL 4TEGRETOL-XR 4TRILEPTAL SUSP 4VIMPAT INJ 4VIMPAT ORAL SOLN 4 QL (1200 ML per 30 days)VIMPAT TABS 4 QL (60 EA per 30 days)Antidementia AgentsAntidementia Agents, Otherergoloid mesylates 2 MO GCCholinesterase Inhibitorsdonepezil hcl 1 MO GCEXELON PT24 3 QL (30 EA per 30 days) MOEXELON SOLN 4galantamine hydrobromide 2 MO GCrivastigmine tartrate 2 MO GCN-methyl-D-aspartate (NMDA) Receptor AntagonistNAMENDA TITRATION PAK 3 QL (49 EA per 30 days) MONAMENDA SOLN 3 QL (300 ML per 30 days) MONAMENDA TABS 3 QL (60 EA per 30 days) MOAntidepressantsAntidepressants, OtherAPLENZIN 4 STbudeprion sr 1 MO GCbuproban 1 MO GCbupropion hcl 1 MO GCbupropion hcl sr tb12 200mg 1 MO GCFORFIVO XL 4 QL (30 EA per 30 days)maprotiline hcl 2 MO GCmirtazapine 1 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 11 of 73

Drug NameDrugTier Requirements/Limitsmirtazapine odt tbdp 30mg, 45mg 1 MO GCnefazodone hcl 2 MO GCSEROQUEL XR TB24 150MG, 200MG 4 QL (30 EA per 30 days)SEROQUEL XR TB24 300MG, 400MG, 50MG 4 QL (60 EA per 30 days)trazodone hcl tabs 100mg, 150mg, 50mg 1 MO GCtrazodone hcl tabs 300mg 2 MO GCVIIBRYD TABS 4 QL (30 EA per 30 days) STVIIBRYD KIT 4 QL (60 EA per 30 days) STAntidepressantschlordiazepoxide/amitriptyline 2 PA MO GCfluoxetine hcl 2 QL (30 EA per 30 days) MO GColanzapine/fluoxetine caps 25mg, 3mg 2 QL (30 EA per 30 days) MO GColanzapine/fluoxetine caps 25mg, 12mg, 50mg, 12mg, 50mg, 2 QL (60 EA per 30 days) MO GC6mgolanzapine/fluoxetine caps 25mg, 6mg 2 QL (90 EA per 30 days) MOperphenazine/amitriptyline 1 MO GCSYMBYAX CAPS 25MG, 3MG 4 QL (30 EA per 30 days)SYMBYAX CAPS 50MG, 6MG 4 QL (60 EA per 30 days)SYMBYAX CAPS 25MG, 6MG 4 QL (90 EA per 30 days)SYMBYAX CAPS 25MG, 12MG, 50MG, 12MG 5 QL (60 EA per 30 days)Monoamine Oxidase InhibitorsEMSAM PT24 6MG/24HR, 9MG/24HR 4 QL (30 EA per 30 days)EMSAM PT24 12MG/24HR 5 QL (30 EA per 30 days)MARPLAN 4phenelzine sulfate 1 MO GCtranylcypromine sulfate 2 MO GCSerotonin/ Norepinephrine Reuptake Inhibitorscitalopram hydrobromide 1 MO GCCYMBALTA CPEP 60MG 4 QL (30 EA per 30 days) STCYMBALTA CPEP 20MG, 30MG 4 QL (60 EA per 30 days) STescitalopram oxalate soln 2 QL (600 ML per 30 days) MO GCescitalopram oxalate tabs 10mg 2 MO GCescitalopram oxalate tabs 20mg, 5mg 2 QL (30 EA per 30 days) MO GCfluoxetine hcl 1 MO GCfluvoxamine maleate 1 MO GCparoxetine hcl 1 MO GCparoxetine hcl er 2 MO GCPAXIL 4 STPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 12 of 73

Drug NameDrugTier Requirements/LimitsPEXEVA 4 QL (30 EA per 30 days) STPRISTIQ 4 QL (30 EA per 30 days) STsertraline hcl 1 MO GCvenlafaxine hcl 1 MO GCVENLAFAXINE HCL ER 4 STTricyclicsamitriptyline hcl 1 MO GCamoxapine tabs 100mg, 25mg, 50mg 1 MO GCclomipramine hcl 1 MO GCdesipramine hcl 2 MO GCdoxepin hcl 1 MO GCimipramine hcl 1 MO GCIMIPRAMINE PAMOATE CAPS 125MG 4 QL (30 EA per 30 days)imipramine pamoate caps 100mg, 150mg, 75mg 2 MO GCnortriptyline hcl caps 1 MO GCprotriptyline hcl 2 MO GCSILENOR 4trimipramine maleate 2 MO GCAntiemeticsAntiemetics, Otherchlorpromazine hcl 1 MO GCcompro 1 MO GCdiphenhydramine hcl caps 50mg 1 PA MO GChydroxyzine hcl 1 PA MO GChydroxyzine pamoate 1 PA MO GCmeclizine hcl 1 MO GCmetoclopramide hcl 1 MO GCperphenazine 1 MO GCphenadoz 1 PA MO GCprochlorperazine edisylate 1 MO GCprochlorperazine maleate 1 MO GCpromethazine hcl 1 PA MO GCpromethegan supp 25mg, 50mg 1 PA MO GCTRANSDERM-SCOP 4trimethobenzamide hcl caps 1 PA MO GCEmetogenic Therapy AdjunctsALOXI 4DRONABINOL CAPS 10MG 5 QL (60 EA per 30 days) B/DPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 13 of 73

Drug NameDrugTier Requirements/Limitsdronabinol caps 2.5mg, 5mg 2 QL (60 EA per 30 days) B/D MOGCEMEND CAPS 125MG, 40MG 4 QL (1 EA per 1 days) B/DEMEND CAPS 80MG 4 QL (2 EA per 1 days) B/DEMEND CAPS 0 4 QL (3 EA per 1 days) B/Dgranisetron hcl tabs 2 QL (60 EA per 30 days) B/D MOGCgranisetron hcl inj 1mg/ml 2 QL (14 ML per 30 days) B/D MOGCondansetron hcl soln 2 QL (450 ML per 30 days) B/D MOGCondansetron hcl tabs 24mg 2 B/D MO GCondansetron hcl tabs 4mg, 8mg 2 QL (9 EA per 3 days) B/D MO GCondansetron odt tbdp 8mg 2 QL (45 EA per 30 days) B/D MOGCondansetron odt tbdp 4mg 2 QL (9 EA per 3 days) B/D MO GCSANCUSO 5 QL (4 EA per 28 days) B/DAntifungalsAntifungalsABELCET 4 B/DAMBISOME 4 B/DAMPHOTEC INJ 50MG 4 B/Damphotericin b 2 B/D MO GCANCOBON 4CANCIDAS INJ 70MG 5 PAciclopirox 1 MO GCciclopirox nail lacquer 1 PA MO GCciclopirox olamine 1 MO GCclotrimazole soln, troc 1 MO GCeconazole nitrate 1 MO GCERTACZO 4EXELDERM 4fluconazole 1 MO GCfluconazole in dextrose inj 56mg/ml, 400mg/200ml 1 MO GCflucytosine 2 MO GCGRIS-PEG 4griseofulvin microsize tabs 2 MO GCgriseofulvin microsize susp 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 14 of 73

Drug NameDrugTier Requirements/Limitsgriseofulvin ultramicrosize 2 MOitraconazole 2 QL (120 EA per 30 days) PA MOGCketoconazole crea, sham, tabs 1 MO GCketoconazole foam 2 MO GCMENTAX 4miconazole 3 1 MO GCMYCAMINE 5NAFTIN GEL 4NAFTIN CREA 1% 4NATACYN 4NOXAFIL 5 PAnystatin crea, oint, susp, tabs 1 MO GCnystop 1 MO GCONMEL 4 PAOXISTAT 4pedi-dri 1 MO GCSPORANOX SOLN 5 PAterbinafine hcl tabs 1 QL (30 EA per 30 days) PA MO GCterconazole crea 0.8% 1 MO GCterconazole crea 0.4% 1 MO GCterconazole supp 1 MO GCVFEND IV 4 PAvoriconazole inj 2 PA MO GCVORICONAZOLE TABS 50MG 5 QL (120 EA per 30 days) PAVORICONAZOLE TABS 200MG 5 QL (60 EA per 30 days) PAzazole crea 1 MO GCZOLINZA 5 QL (120 EA per 30 days) PAAntigout AgentsAntigout Agentsallopurinol 1 MO GCCOLCRYS 4 QL (120 EA per 30 days)probenecid 1 MO GCprobenecid/colchicine 1 MO GCULORIC 4 PAAntimigraine AgentsErgot Alkaloidsdihydroergotamine mesylate 2 MO GCMIGERGOT 4PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 15 of 73

Drug NameDrugTier Requirements/LimitsMIGRANAL 5 QL (12 ML per 30 days)ProphylacticBOTOX INJ 100UNIT 4 PAtimolol maleate 1 MO GCSerotonin (5-HT) 1b/1d Receptor AgonistsAXERT TABS 12.5MG 4 QL (24 EA per 28 days)FROVA 4 QL (12 EA per 30 days)IMITREX SOLN 4MAXALT 4 QL (12 EA per 30 days)MAXALT-MLT 4 QL (12 EA per 30 days)naratriptan hcl 1 MO GCRELPAX 4 QL (9 EA per 30 days)rizatriptan benzoate 2 QL (12 EA per 28 days) MO GCsumatriptan succinate tabs 1 MO GCsumatriptan succinate inj 6mg/0.5ml 2 MO GCZOMIG ZMT 4 QL (9 EA per 30 days)ZOMIG SOLN 4 QL (6 EA per 30 days)ZOMIG TABS 4 QL (9 EA per 30 days)Antimyasthenic AgentsParasympathomimeticsMESTINON TIMESPAN 4MESTINON SYRP 4pyridostigmine bromide 1 MO GCAntimycobacterialsAntimycobacterials, OtherACZONE 4 PADAPSONE 3 MOMYCOBUTIN 4Antitubercularsethambutol hcl 1 MO GCisoniazid tabs 1 MO GCrifampin 1 MO GCRIFATER 4AntineoplasticsAlkylating AgentsCEENU 4cyclophosphamide tabs 2 B/D MO GCHEXALEN 5 PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 16 of 73

Drug NameDrugTier Requirements/LimitsLEUKERAN 4MATULANE 5Antiangiogenic AgentsREVLIMID CAPS 15MG, 25MG 5 QL (21 EA per 28 days) PA LAREVLIMID CAPS 10MG, 5MG 5 QL (30 EA per 30 days) PA LATHALOMID CAPS 100MG, 50MG 5 QL (30 EA per 30 days) PATHALOMID CAPS 150MG, 200MG 5 QL (60 EA per 30 days) PAAntiestrogens/ModifiersEMCYT 4 PAFARESTON 4tamoxifen citrate 1 MO GCAntimetabolitesDROXIA CAPS 300MG 4GEMCITABINE HCL INJ 1GM 5hydroxyurea 1 MO GCTABLOID 4Antineoplastics, Otheramifostine 1 MO GCCOMETRIQ 5 PAICLUSIG TABS 45MG 5 PAICLUSIG TABS 15MG 5 QL (60 EA per 30 days) PAleucovorin calcium tabs 1 MO GCleucovorin calcium inj 100mg, 350mg 1 MO GCmitoxantrone hcl 1 MO GCSYNRIBO 5 PAYERVOY 5 PAZALTRAP INJ 100MG/4ML 5 PAZELBORAF 5 QL (240 EA per 30 days) PAAntineoplasticsadriamycin inj 2mg/ml 2 MO GCALIMTA 5ARRANON 5AVASTIN 5 PACAMPATH 5carboplatin inj 150mg/15ml 2 MO GCCYTARABINE AQUEOUS 4DACOGEN 5dexrazoxane inj 500mg 5DOCETAXEL INJ 80MG/8ML 5PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 17 of 73

Drug NameDrugTier Requirements/LimitsDOXIL 5ELOXATIN INJ 100MG/20ML 5ERBITUX 5 PAERIVEDGE 5 PAFASLODEX 4HERCEPTIN 5INLYTA 5 PAirinotecan inj 100mg/5ml 2 MO GCIXEMPRA KIT INJ 45MG 5 PAJEVTANA 5 PAmesna 2 MO GCMESNEX TABS 5mitomycin inj 20mg 2 MO GCMUSTARGEN 4PACLITAXEL INJ 300MG/50ML 4PERJETA 5 PAPROLEUKIN 5 PASTIVARGA 5 PATAXOTERE INJ 80MG/4ML 5 PATREANDA 5VECTIBIX 5 PAVELCADE 5VIDAZA 5VINCASAR PFS 4XTANDI 5 QL (120 EA per 30 days) PAAromatase Inhibitors, 3rd Generationanastrozole 1 MO GCexemestane 2 MO GCletrozole 1 MO GCEnzyme InhibitorsETOPOSIDE INJ 3 MOJAKAFI 3 QL (60 EA per 30 days) PA MOMolecular Target InhibitorsAFINITOR TABS 7.5MG 5 QL (30 EA per 30 days) PAAFINITOR TABS 10MG 5 QL (60 EA per 30 days) PAAFINITOR TABS 5MG 5 QL (90 EA per 30 days) PABOSULIF 5 PACAPRELSA TABS 100MG 5 QL (60 EA per 30 days) PA LAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 18 of 73

Drug NameDrugTier Requirements/LimitsCAPRELSA TABS 300MG 5 QL (90 EA per 90 days) PA LAGLEEVEC TABS 400MG 5 QL (60 EA per 30 days) PAGLEEVEC TABS 100MG 5 QL (90 EA per 30 days) PANEXAVAR 5 QL (120 EA per 30 days) PA LASPRYCEL TABS 20MG 5 QL (150 EA per 30 days) PASPRYCEL TABS 140MG, 80MG 5 QL (30 EA per 30 days) PASPRYCEL TABS 100MG, 50MG, 70MG 5 QL (60 EA per 30 days) PASUTENT CAPS 25MG, 50MG 5 QL (30 EA per 30 days) PASUTENT CAPS 12.5MG 5 QL (90 EA per 30 days) PATARCEVA TABS 25MG 5 QL (60 EA per 30 days) PATARCEVA TABS 100MG, 150MG 5 QL (90 EA per 90 days) PATASIGNA 5 QL (120 EA per 30 days) PATYKERB 5 QL (540 EA per 90 days) PA LAVOTRIENT 5 QL (360 EA per 90 days) PAXALKORI 5 QL (60 EA per 30 days) PAMonoclonal AntibodiesARZERRA INJ 100MG/5ML 5 PARITUXAN 5 PARetinoidsPANRETIN 5 PATARGRETIN 5 PATRETINOIN CAPS 3 MOtretinoin crea, gel 2 PA MO GCAntiparasiticsAnthelminticsALBENZA 3 MOBILTRICIDE 3 MOSTROMECTOL 3 MOAntiprotozoalsALINIA TABS 4atovaquone/proguanil hcl tabs 250mg, 100mg 2 MO GCchloroquine phosphate 1 MO GCDARAPRIM 4hydroxychloroquine sulfate 1 MO GCmefloquine hcl 2 MO GCMEPRON 5NEBUPENT 4 B/DQUALAQUIN 4 QL (42 EA per 30 days)quinine sulfate 2 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 19 of 73

Drug NameDrugTier Requirements/Limitstinidazole 2 MO GCPediculicides/ ScabicidesEURAX 4LINDANE SHAM 4lindane lotn 2 MO GCmalathion 2 MO GCpermethrin 1 MO GCSKLICE 4Antiparkinson AgentsAnticholinergicsbenztropine mesylate 1 MO GCtrihexyphenidyl hcl tabs 1 MO GCAntiparkinson Agents, Otheramantadine hcl 1 MO GCCOMTAN 4 QL (240 EA per 30 days)TASMAR 5 QL (90 EA per 30 days)Antiparkinson AgentsSTALEVO 100 4 QL (240 EA per 30 days)STALEVO 125 4 QL (240 EA per 30 days)STALEVO 150 4 QL (240 EA per 30 days)STALEVO 200 4 QL (240 EA per 30 days)STALEVO 50 4 QL (240 EA per 30 days)STALEVO 75 4 QL (240 EA per 30 days)Dopamine AgonistsAPOKYN 5 QL (60 ML per 30 days) PA LAbromocriptine mesylate 2 MO GCpramipexole dihydrochloride 1 MO GCropinirole er 2 MO GCropinirole hcl 1 MO GCDopamine Precursors/ L-Amino Acid Decarboxylase Inhibitorscarbidopa/levodopa 1 MO GCcarbidopa/levodopa er 1 MO GCLODOSYN 4Monoamine Oxidase B (MAO-B) InhibitorsAZILECT 4 QL (30 EA per 30 days)selegiline hcl 2 MO GCZELAPAR 4AntipsychoticsPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 20 of 73

Drug NameDrugTier Requirements/Limits1st Generation/ Typicalfluphenazine decanoate 1 MO GCfluphenazine hcl 1 MO GChaloperidol 1 MO GChaloperidol decanoate 1 MO GChaloperidol lactate 1 MO GCloxapine succinate 2 MO GCORAP 3 MOthioridazine hcl 1 PA MO GCthiothixene 1 MO GCtrifluoperazine hcl 1 MO GC2nd Generation/ AtypicalABILIFY DISCMELT TBDP 10MG 4 QL (60 EA per 30 days)ABILIFY DISCMELT TBDP 15MG 5 QL (60 EA per 30 days)ABILIFY INJ 4ABILIFY ORAL SOLN 4 QL (900 ML per 30 days) STABILIFY TABS 10MG, 15MG, 2MG, 5MG 4 QL (30 EA per 30 days) STABILIFY TABS 20MG, 30MG 5 QL (30 EA per 30 days) STFANAPT TABS 1MG, 2MG, 4MG 4 QL (30 EA per 30 days) STFANAPT TABS 10MG, 12MG, 6MG, 8MG 4 QL (60 EA per 30 days) STGEODON 4 QL (300 EA per 30 days)INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML 4 QL (1 ML per 28 days)INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 5 QL (1 ML per 28 days)234MG/1.5MLINVEGA TB24 1.5MG, 3MG 4 QL (30 EA per 30 days) STINVEGA TB24 6MG 4 QL (60 EA per 30 days) STINVEGA TB24 9MG 5 QL (30 EA per 30 days) STLATUDA TABS 120MG, 20MG, 80MG 4 QL (30 EA per 30 days) STLATUDA TABS 40MG 4 QL (90 EA per 30 days) STolanzapine 2 MO GColanzapine odt 2 MO GCquetiapine fumarate 2 MO GCRISPERDAL CONSTA INJ 12.5MG, 25MG 4 QL (2 EA per 28 days)RISPERDAL CONSTA INJ 37.5MG 5 QL (1 EA per 28 days)RISPERDAL CONSTA INJ 50MG 5 QL (2 EA per 28 days)risperidone 1 MO GCrisperidone odt 1 MO GCSAPHRIS 4 QL (60 EA per 30 days)ziprasidone hcl 2 QL (60 EA per 30 days) MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 21 of 73

Drug NameDrugTier Requirements/LimitsTreatment-Resistantclozapine 2 MO GCFAZACLO TBDP 100MG, 25MG 4Antispasticity AgentsAntispasticity Agentsbaclofen 1 MO GCdantrolene sodium caps 2 MO GCtizanidine hcl 1 MO GCXEOMIN 4 PAAntiviralsAnti-cytomegalovirus (CMV) AgentsCIDOFOVIR 5foscarnet sodium 2 MO GCganciclovir 2 B/D MO GCVALCYTE TABS 5 QL (84 EA per 30 days)ZIRGAN 4Anti-HIV Agents, Non-nucleoside Reverse TranscriptaseInhibitorsEDURANT 5INTELENCE TABS 100MG 5 QL (120 EA per 30 days)INTELENCE TABS 200MG 5 QL (60 EA per 30 days)nevirapine tabs 2 MO GCRESCRIPTOR TABS 200MG 3 MORESCRIPTOR TABS 100MG 4SUSTIVA 4VIRAMUNE XR 4VIRAMUNE SUSP 4Anti-HIV Agents, Nucleoside and Nucleotide ReverseTranscriptase Inhibitorsabacavir 2 MO GCCOMPLERA 5didanosine 2 MO GCEMTRIVA 4EPIVIR SOLN 4EPZICOM 5lamivudine 2 MO GCLAMIVUDINE/ZIDOVUDINE 5RETROVIR IV INFUSION 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 22 of 73

Drug NameDrugTier Requirements/Limitsstavudine solr 2 MO GCstavudine caps 2 MO GCTRIZIVIR 5TRUVADA 5VIDEX PEDIATRIC SOLR 2GM 4VIREAD POWD 4VIREAD TABS 5ZERIT SOLR 4ZIAGEN 4zidovudine 1 MO GCAnti-HIV Agents, OtherFUZEON INJ 90MG 5 QL (60 EA per 30 days)ISENTRESS CHEW 3 MOISENTRESS TABS 5 QL (60 EA per 30 days)SELZENTRY TABS 300MG 5 QL (120 EA per 30 days)SELZENTRY TABS 150MG 5 QL (60 EA per 30 days)STRIBILD 5 QL (30 EA per 30 days)Anti-HIV Agents, Protease InhibitorsAPTIVUS SOLN 5APTIVUS CAPS 5 QL (120 EA per 30 days)CRIXIVAN CAPS 400MG 3 MOINVIRASE CAPS 4INVIRASE TABS 5KALETRA SOLN 5KALETRA TABS 100MG, 25MG 4KALETRA TABS 200MG, 50MG 5LEXIVA SUSP 4LEXIVA TABS 5NORVIR 4PREZISTA TABS 75MG 4PREZISTA TABS 150MG, 400MG, 600MG, 800MG 5REYATAZ CAPS 100MG 4REYATAZ CAPS 150MG, 200MG, 300MG 5VIRACEPT 5Anti-influenza AgentsRELENZA DISKHALER 4 QL (60 EA per 180 days)rimantadine hcl 2 MO GCTAMIFLU CAPS 45MG, 75MG 4 QL (28 EA per 180 days)Antihepatitis AgentsPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 23 of 73

Drug NameDrugTier Requirements/LimitsBARACLUDE SOLN 4 QL (600 ML per 30 days)BARACLUDE TABS 1MG 5 QL (30 EA per 30 days)BARACLUDE TABS 0.5MG 5 QL (60 EA per 30 days)EPIVIR HBV 4HEPSERA 5 QL (30 EA per 30 days)INCIVEK 5 QL (504 EA per 84 days) PAINTRON-A W/DILUENT INJ 10MU 4 PAINTRON-A INJ 6000000UNIT/ML 4 PAPEG-INTRON REDIPEN 5 QL (4 EA per 28 days) ST PAPEG-INTRON INJ 50MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEGASYS PROCLICK INJ 135MCG/0.5ML 5 QL (4 ML per 28 days) PAPEGASYS INJ 180MCG/0.5ML 5 QL (2 EA per 28 days) PAPEGASYS INJ 180MCG/ML 5 QL (4 ML per 28 days) PARIBAPAK TABS 400MG 5 PAribasphere caps 2 PA MO GCRIBASPHERE TABS 200MG 4 PARIBASPHERE TABS 400MG, 600MG 5 PAribavirin 2 PA MO GCSYLATRON 5 QL (4 EA per 28 days) PATYZEKA 5 QL (30 EA per 30 days)VICTRELIS 5 QL (360 EA per 30 days) PAVIRAZOLE 5 B/DAntiherpetic Agentsacyclovir 1 MO GCacyclovir sodium inj 500mg 1 MO GCDENAVIR 4 QL (5 GM per 30 days)famciclovir 2 MO GCtrifluridine 2 MO GCvalacyclovir hcl 2 MO GCZOVIRAX CREA 4 QL (15 GM per 30 days)ZOVIRAX OINT 4 QL (30 GM per 30 days)AntiviralsATRIPLA 5AnxiolyticsAnxiolytics, Otheralprazolam er tb24 0.5mg 2 QL (120 EA per 30 days) MO GCalprazolam intensol 2 QL (60 ML per 30 days) MO GCalprazolam odt tbdp 0.25mg, 0.5mg 2 QL (120 EA per 30 days) MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 24 of 73

Drug NameDrugTier Requirements/Limitsalprazolam odt tbdp 1mg, 2mg 2 QL (60 EA per 30 days) MO GCalprazolam xr tb24 1mg, 2mg, 3mg 2 QL (60 EA per 30 days) MO GCalprazolam tabs 0.25mg, 0.5mg 2 QL (120 EA per 30 days) MO GCalprazolam tabs 1mg, 2mg 2 QL (60 EA per 30 days) MO GCbuspirone hcl tabs 10mg, 15mg, 30mg, 5mg 1 MO GCbuspirone hcl tabs 7.5mg 2 MO GCclonazepam odt tbdp 2mg 2 QL (300 EA per 30 days) PA MOGCclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg 2 QL (90 EA per 30 days) PA MO GCclonazepam tabs 2mg 1 QL (300 EA per 30 days) PA MOGCclonazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days) PA MO GCclorazepate dipotassium 2 QL (90 EA per 30 days) PA MO GCDIAZEPAM GEL 4 PAdiazepam soln 1 QL (1200 ML per 30 days) PA MOGCdiazepam tabs 10mg 1 QL (120 EA per 30 days) PA MOGCdiazepam tabs 2mg, 5mg 1 QL (60 EA per 30 days) PA MO GClorazepam intensol 2 QL (45 ML per 30 days) MO GClorazepam tabs 0.5mg 2 QL (180 EA per 30 days) MO GClorazepam tabs 2mg 2 QL (30 EA per 30 days) MO GClorazepam tabs 1mg 2 QL (90 EA per 30 days) MO GCmeprobamate 2 PA MO GCtemazepam 2 QL (30 EA per 30 days) MO GCSSRIs/ SNRIsvenlafaxine hcl er 1 MO GCBipolar AgentsMood Stabilizerscarbamazepine er 2 MO GClithium carbonate 1 MO GClithium carbonate er 1 MO GClithium citrate 1 MO GCBlood Glucose RegulatorsAntidiabetic Agentsacarbose 1 QL (90 EA per 30 days) MO GCACTOS 4 QL (30 EA per 30 days) GC DAVANDIA TABS 8MG 4 QL (30 EA per 30 days) GC DAVANDIA TABS 2MG, 4MG 4 QL (60 EA per 30 days) GC DPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 25 of 73

Drug NameDrugTier Requirements/LimitsBYDUREON 3 QL (4 EA per 28 days) MOBYETTA INJ 10MCG/0.04ML 4 QL (2.4 ML per 28 days)BYETTA INJ 5MCG/0.02ML 4 QL (4.8 ML per 28 days)chlorpropamide tabs 100mg 2 QL (210 EA per 30 days) PA MOGCchlorpropamide tabs 250mg 2 QL (90 EA per 30 days) PA MO GCCYCLOSET 4 QL (180 EA per 30 days)glimepiride tabs 2mg 1 QL (120 EA per 30 days) MO GCglimepiride tabs 1mg 1 QL (240 EA per 30 days) MO GCglimepiride tabs 4mg 1 QL (60 EA per 30 days) MO GCglipizide er tb24 5mg 1 QL (120 EA per 30 days) MO GCglipizide er tb24 2.5mg 1 QL (240 EA per 30 days) MO GCglipizide er tb24 10mg 1 QL (60 EA per 30 days) MO GCglipizide tabs 10mg 1 QL (120 EA per 30 days) MO GCglipizide tabs 5mg 1 QL (240 EA per 30 days) MO GCglyburide micronized tabs 3mg 1 QL (120 EA per 30 days) MO GCglyburide micronized tabs 1.5mg 1 QL (240 EA per 30 days) MO GCglyburide micronized tabs 6mg 1 QL (60 EA per 30 days) MO GCglyburide tabs 5mg 1 QL (120 EA per 30 days) MO GCglyburide tabs 2.5mg 1 QL (240 EA per 30 days) MO GCglyburide tabs 1.25mg 1 QL (480 EA per 30 days) MO GCGLYSET 4 QL (90 EA per 30 days)JANUVIA 3 QL (30 EA per 30 days) MO GC Dmetformin hcl er tb24 500mg 1 QL (120 EA per 30 days) MO GCmetformin hcl er tb24 750mg 1 QL (60 EA per 30 days) MO GCmetformin hcl tabs 500mg 1 QL (150 EA per 30 days) MO GCmetformin hcl tabs 1000mg 1 QL (60 EA per 30 days) MO GCmetformin hcl tabs 850mg 1 QL (90 EA per 30 days) MO GCnateglinide 1 QL (90 EA per 30 days) MO GCONGLYZA TABS 5MG 4 QL (30 EA per 30 days) GC DONGLYZA TABS 2.5MG 4 QL (60 EA per 30 days) GC Dpioglitazone hcl 2 QL (30 EA per 30 days) MOPRANDIN TABS 0.5MG, 1MG 4 QL (120 EA per 30 days)PRANDIN TABS 2MG 4 QL (240 EA per 30 days)SYMLINPEN 120 4SYMLINPEN 60 4tolazamide tabs 500mg 1 QL (180 EA per 30 days) MO GCtolbutamide 1 QL (180 EA per 30 days) MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 26 of 73

Drug NameDrugTier Requirements/LimitsTRADJENTA 3 QL (30 EA per 30 days) MOVICTOZA 4 QL (18 ML per 28 days)WELCHOL 3 MOBlood Glucose RegulatorsACTOPLUS MET 4 GC DACTOPLUS MET XR 4 GC DAVANDAMET 4 GC DAVANDARYL 4 GC Dglipizide/metformin hcl tabs 2.5mg, 500mg, 5mg, 500mg 1 QL (120 EA per 30 days) MO GCglipizide/metformin hcl tabs 2.5mg, 250mg 1 QL (240 EA per 30 days) MO GCglyburide/metformin hcl tabs 2.5mg, 500mg, 5mg, 500mg 1 QL (120 EA per 30 days) MO GCglyburide/metformin hcl tabs 1.25mg, 250mg 1 QL (240 EA per 30 days) MO GCJANUMET 3 QL (60 EA per 30 days) MOJANUMET XR 3 QL (30 EA per 30 days) MOKOMBIGLYZE XR TB24 1000MG, 5MG, 500MG, 5MG 4 QL (30 EA per 30 days)KOMBIGLYZE XR TB24 1000MG, 2.5MG 4 QL (60 EA per 30 days)pioglitazone hcl-glimepiride 2 MO GCpioglitazone hcl/metformin hcl 2 MO GCPRANDIMET 4 QL (150 EA per 30 days)Glycemic AgentsGLUCAGEN HYPOKIT 4GLUCAGON EMERGENCY KIT 3 MOPROGLYCEM 4InsulinsAPIDRA 4 GC DAPIDRA SOLOSTAR 4 GC Dbd insulin syringe safetyglide/1ml/29g x 1/2" 2 MO GCbd insulin syringe ultrafine/0.3ml/31g x 5/16" 2 MO GCbd insulin syringe ultrafine/0.5ml/30g x 1/2" 2 MO GCbd insulin syringe ultrafine/1ml/31g x 5/16" 2 MO GCbd pen needle/ultrafine/29g x 12.7mm 2 MO GCcurity gauze pads 2"x2" 2 MO GCHUMALOG 3 MO GC DHUMALOG KWIKPEN 3 MO GC DHUMALOG MIX 50/50 3 MO GC DHUMALOG MIX 50/50 KWIKPEN 3 MO GC DHUMALOG MIX 75/25 3 MO GC DHUMALOG MIX 75/25 KWIKPEN 3 MO GC DHUMULIN 70/30 3 MO GC DPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 27 of 73

Drug NameDrugTier Requirements/LimitsHUMULIN 70/30 PEN 3 MO GC DHUMULIN N 3 MO GC DHUMULIN N U-100 PEN 3 MO GC DHUMULIN R 3 MO GC DHUMULIN R U-500 (CONCENTRATED) 3 MO GC DLANTUS 3 MO GC DLANTUS SOLOSTAR 3 MO GC DLEVEMIR 3 MOLEVEMIR FLEXPEN 3 MONOVOLIN 70/30 3 MO GC DNOVOLIN N 3 MO GC DNOVOLIN R 3 MO GC DNOVOLOG 3 MO GC DNOVOLOG FLEXPEN 3 MO GC DNOVOLOG MIX 70/30 3 MO GC DNOVOLOG MIX 70/30 PREFILLED FLEXPEN 3 MO GC DBlood Products/ Modifiers/ Volume ExpandersAnticoagulantsCOUMADIN 4ENOXAPARIN SODIUM INJ 80MG/0.8ML 4 QL (28 ML per 30 days)ENOXAPARIN SODIUM INJ 100MG/ML, 120MG/0.8ML, 5 QL (28 ML per 30 days)150MG/MLenoxaparin sodium inj 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml 2 QL (28 ML per 30 days) MO GCFONDAPARINUX SODIUM INJ 2.5MG/0.5ML 4 QL (14 ML per 28 days)FONDAPARINUX SODIUM INJ 10MG/0.8ML,5 QL (14 ML per 28 days)5MG/0.4ML, 7.5MG/0.6MLFRAGMIN INJ 2500UNIT/0.2ML 4 QL (14 ML per 28 days)FRAGMIN INJ 12500UNIT/0.5ML, 15000UNIT/0.6ML, 5 QL (14 ML per 28 days)18000UNT/0.72ML, 7500UNIT/0.3MLheparin sodium 1 B/D MO GCheparin sodium/nacl 0.45% 1 B/D MO GCjantoven 1 MO GCLOVENOX 4 QL (28 ML per 30 days)PRADAXA 4warfarin sodium 1 MO GCXARELTO TABS 15MG, 20MG 3 QL (30 EA per 30 days) MOXARELTO TABS 10MG 3 QL (35 EA per 365 days) PA MOBlood Formation ModifiersPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 28 of 73

Drug NameDrugTier Requirements/Limitsanagrelide hydrochloride 2 MO GCARANESP ALBUMIN FREE INJ 60MCG/ML 4 QL (2.4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 40MCG/ML 4 QL (3.2 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 25MCG/ML 4 QL (4 ML per 30 days) ST PAARANESP ALBUMIN FREE INJ 500MCG/ML 5 QL (1 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 200MCG/ML 5 QL (1.6 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 300MCG/0.6ML 5 QL (2.4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 100MCG/ML 5 QL (4 ML per 28 days) ST PALEUKINE 5 PANEULASTA 5 PANEUPOGEN 5 PAPROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,4 QL (12 ML per 30 days) PA3000UNIT/ML, 4000UNIT/MLPROCRIT INJ 20000UNIT/ML, 40000UNIT/ML 5 QL (12 ML per 30 days) PAPROMACTA 5 QL (30 EA per 30 days) PABlood Products/ Modifiers/ Volume ExpandersCINRYZE 5 PANEUMEGA 5 PACoagulantstranexamic acid 2 MO GCPlatelet Modifying AgentsAGGRENOX 4 QL (60 EA per 30 days)cilostazol 1 MO GCclopidogrel tabs 300mg 2 MO GCclopidogrel tabs 75mg 2 QL (34 EA per 30 days) MO GCdipyridamole 1 PA MO GCEFFIENT TABS 10MG 4 QL (36 EA per 30 days)EFFIENT TABS 5MG 4 QL (43 EA per 30 days)ticlopidine hcl 1 MO GCCardiovascular AgentsAlpha-adrenergic Agonistsclonidine hcl tabs 1 MO GCclonidine hcl ptwk 2 MO GCguanfacine hcl 1 MO GCmethyldopa 2 MO GCmidodrine hcl 2 MO GCAlpha-adrenergic Blocking AgentsDIBENZYLINE 4doxazosin mesylate 1 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 29 of 73

Drug NameDrugTier Requirements/Limitsprazosin hcl 1 MO GCterazosin hcl 1 MO GCAngiotensin II Receptor AntagonistsBENICAR 3 QL (30 EA per 30 days) MODIOVAN 4EDARBI 4 QL (30 EA per 30 days) STeprosartan mesylate 2 MO GCirbesartan 2 QL (30 EA per 30 days) MO GClosartan potassium 1 MO GCMICARDIS 3 QL (30 EA per 30 days) MOAngiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 MO GCcaptopril 1 MO GCenalapril maleate 1 MO GCfosinopril sodium 1 MO GClisinopril 1 MO GCmoexipril hcl 2 MO GCperindopril erbumine 2 MO GCquinapril hcl 1 MO GCramipril 1 MO GCtrandolapril 1 MO GCAntiarrhythmicsamiodarone hcl tabs 400mg 1 MO GCdisopyramide phosphate 1 MO GCflecainide acetate 1 MO GCmexiletine hcl 1 MO GCMULTAQ 4NORPACE CR CP12 100MG 4PACERONE TABS 100MG 4pacerone tabs 200mg 1 MO GCpropafenone hcl 1 MO GCpropafenone hcl er 2 MO GCquinidine gluconate er 1 MO GCquinidine sulfate 1 MO GCquinidine sulfate er 1 MO GCsorine 1 MO GCsotalol hcl (af) tabs 120mg 1 MO GCsotalol hcl tabs 160mg, 240mg, 80mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 30 of 73

Drug NameDrugTier Requirements/LimitsTIKOSYN 4Beta-adrenergic Blocking Agentsacebutolol hcl 1 MO GCatenolol 1 MO GCbetaxolol hcl tabs 10mg 1 MO GCbetaxolol hcl tabs 20mg 1 MO GCbisoprolol fumarate 1 MO GCBYSTOLIC TABS 10MG 3 QL (120 EA per 30 days) MOBYSTOLIC TABS 2.5MG 3 QL (30 EA per 30 days) MOBYSTOLIC TABS 20MG 3 QL (60 EA per 30 days) MOBYSTOLIC TABS 5MG 3 QL (90 EA per 30 days) MOcarvedilol 1 MO GCCOREG CR 4INNOPRAN XL 4labetalol hcl tabs 1 MO GCLEVATOL 4metoprolol succinate er 1 MO GCmetoprolol tartrate tabs 1 MO GCnadolol 1 MO GCpindolol 1 MO GCpropranolol hcl er 1 MO GCpropranolol hcl tabs 1 MO GCCalcium Channel Blocking Agentsafeditab cr 1 MO GCamlodipine besylate 1 MO GCcartia xt 1 MO GCdilt-cd cp24 120mg, 300mg 1 MO GCdilt-xr cp24 180mg, 240mg 1 MO GCdiltiazem cd cp24 120mg, 240mg, 300mg 1 MO GCdiltiazem hcl er cp24 180mg, 360mg 1 MO GCdiltiazem hcl er cp12 1 MO GCdiltiazem hcl tabs 1 MO GCDYNACIRC CR TB24 5MG 4 QL (30 EA per 30 days)DYNACIRC CR TB24 10MG 4 QL (60 EA per 30 days)felodipine er 1 MO GCisradipine 2 MO GCmatzim la 2 MO GCnicardipine hcl caps 1 MO GCnifediac cc tb24 90mg 1 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 31 of 73

Drug NameDrugTier Requirements/Limitsnifedical xl 1 MO GCnifedipine 2 PA MO GCnifedipine er 1 MO GCNIMODIPINE 4nisoldipine 2 MO GCnisoldipine er 2 MO GCtaztia xt 1 MO GCverapamil hcl er 1 MO GCverapamil hcl tabs 1 MO GCCardiovascular Agents, Otherdigoxin soln, tabs 1 MO GCLANOXIN TABS 4pentoxifylline er 1 MO GCRANEXA 3 QL (120 EA per 30 days) PA MOTEKTURNA 4 QL (30 EA per 30 days) STCardiovascular AgentsADVICOR TB24 40MG, 1000MG 4 QL (30 EA per 30 days)ADVICOR TB24 20MG, 1000MG, 20MG, 500MG, 20MG, 4 QL (60 EA per 30 days)750MGALDACTAZIDE 4amiloride/hydrochlorothiazide 1 MO GCamlodipine besylate/benazepril hcl 2 MO GCamlodipine besylate/benazepril hydrochloride 2 MO GCAMTURNIDE 4 QL (30 EA per 30 days) STatenolol/chlorthalidone 1 MO GCAZOR 3 QL (30 EA per 30 days) ST MObenazepril hcl/hydrochlorothiazide 1 MO GCBENICAR HCT 3 QL (30 EA per 30 days) ST MObisoprolol fumarate/hydrochlorothiazide 1 MO GCcandesartan cilexetil/hydrochlorothiazide 2 MOcaptopril/hydrochlorothiazide 1 MO GCCLORPRES 4 QL (60 EA per 30 days)enalapril maleate/hydrochlorothiazide 1 MO GCEXFORGE 4EXFORGE HCT 4fosinopril sodium/hydrochlorothiazide 1 MO GCirbesartan/hydrochlorothiazide 2 QL (60 EA per 30 days) MO GClisinopril/hydrochlorothiazide 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 32 of 73

Drug NameDrugTier Requirements/Limitslosartan potassium/hydrochlorothiazide 1 MO GCmethyldopa/hydrochlorothiazide 2 MO GCmetoprolol/hydrochlorothiazide 1 MO GCMICARDIS HCT 4 QL (30 EA per 30 days) STmoexipril/hydrochlorothiazide 2 MO GCnadolol/bendroflumethiazide 2 MO GCpropranolol/hydrochlorothiazide 1 MO GCquinapril/hydrochlorothiazide 1 MO GCreserpine 2 MO GCSIMCOR 4 QL (30 EA per 30 days)spironolactone/hydrochlorothiazide 1 MO GCTARKA 4TEKAMLO 4 QL (30 EA per 30 days) STTEKTURNA HCT 4 QL (30 EA per 30 days) STtriamterene/hydrochlorothiazide 1 MO GCTRIBENZOR 3 QL (30 EA per 30 days) ST MOTWYNSTA 3 QL (30 EA per 30 days) ST MOvalsartan/hydrochlorothiazide 2 MOVYTORIN TABS 10MG, 10MG, 10MG, 20MG, 10MG, 4 QL (30 EA per 30 days) ST40MGVYTORIN TABS 10MG, 80MG 4 QL (30 EA per 30 days) ST PADiuretics, Carbonic Anhydrase Inhibitorsacetazolamide 1 MO GCacetazolamide er 2 MO GCmethazolamide 1 MO GCDiuretics, Loopbumetanide 1 MO GCEDECRIN 4furosemide inj, tabs 1 MO GCfurosemide oral soln 10mg/ml 1 MO GCtorsemide tabs 1 MO GCDiuretics, Potassium-sparingamiloride hcl 1 MO GCDYRENIUM 4eplerenone 2 MO GCspironolactone 1 MO GCDiuretics, Thiazidechlorothiazide 1 MO GCchlorthalidone tabs 25mg, 50mg 1 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 33 of 73

Drug NameDrugTier Requirements/Limitshydrochlorothiazide 1 MO GCindapamide 1 MO GCmethyclothiazide 1 MO GCmetolazone 1 MO GCTHALITONE 4Dyslipidemics, Fibric Acid DerivativesANTARA 3 ST MOfenofibrate micronized 1 MO GCfenofibrate tabs 160mg, 54mg 1 MO GCfenofibrate tabs 145mg, 48mg 2 MO GCFENOGLIDE 4 STgemfibrozil 1 QL (60 EA per 30 days) MO GCLIPOFEN CAPS 150MG 3 ST MOLOFIBRA TABS 160MG 4 STNALFON 4TRILIPIX 4 STDyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 2 MO GCCRESTOR 3 QL (30 EA per 30 days) MOfluvastatin caps 20mg 2 QL (30 EA per 30 days) MO GCfluvastatin caps 40mg 2 QL (60 EA per 30 days) MO GCLESCOL XL 4 QL (30 EA per 30 days) STLIVALO 4 QL (30 EA per 30 days) STlovastatin 1 MO GCpravastatin sodium 1 MO GCsimvastatin tabs 10mg, 20mg, 40mg, 5mg 1 MO GCsimvastatin tabs 80mg 1 PA MO GCDyslipidemics, Othercholestyramine light pack 1 MO GCcolestipol hcl 1 MO GCLOVAZA 4 QL (120 EA per 30 days)niacor 1 MO GCNIASPAN 3 QL (60 EA per 30 days) MOprevalite powd 1 MO GCSIMCOR TB24 1000MG, 40MG, 500MG, 40MG 3 QL (60 EA per 30 days) MOVASCEPA 3 MOZETIA 4Vasodilators, Direct-acting Arterial/ VenousPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 34 of 73

Drug NameDrugTier Requirements/LimitsDILATRATE SR 4ISORDIL TITRADOSE 4isosorbide dinitrate 1 MO GCisosorbide dinitrate er 1 MO GCisosorbide mononitrate er 1 MO GCisosorbide mononitrate tabs 10mg 1 MO GCisosorbide mononitrate tabs 20mg 1 MO GCminitran 1 MO GCNITRO-BID 3 MOnitroglycerin 1 MO GCnitroglycerin transdermal 1 MO GCnitrolingual pumpspray 2 MO GCNITROMIST 4NITROSTAT 3 MORECTIV 3 MOVasodilators, Direct-acting Arterialhydralazine hcl tabs 1 MO GCminoxidil 1 MO GCCardiovascular DrugsVasodilating AgentsCIALIS 1 QL (6 EA per 31 days) MO GC EDVIAGRA 1 QL (6 EA per 31 days) MO GC EDCentral Nervous System AgentsAttention Deficit Hyperactivity Disorder Agents, AmphetaminesADDERALL XR CP24 2.5MG, 2.5MG, 2.5MG, 2.5MG, 4 QL (30 EA per 30 days) PA3.75MG, 3.75MG, 3.75MG, 3.75MG, 5MG, 5MG, 5MG,5MG, 6.25MG, 6.25MG, 6.25MG, 6.25MG, 7.5MG, 7.5MG,7.5MG, 7.5MGadderall xr cp24 1.25mg, 1.25mg, 1.25mg, 1.25mg 2 QL (30 EA per 30 days) PA MO GCamphetamine/dextroamphetamine tabs 1 PA MO GCamphetamine/dextroamphetamine cp24 2 QL (30 EA per 30 days) PA MOdextroamphetamine sulfate 1 PA MO GCdextroamphetamine sulfate er 2 PA MO GCmethamphetamine hcl 2 PA MO GCAttention Deficit Hyperactivity Disorder Agents, NonamphetaminesDAYTRANA 4 QL (30 EA per 30 days) PAdexmethylphenidate hcl 1 MO GCFOCALIN XR CP24 10MG, 15MG 4 QL (30 EA per 30 days) PAPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 35 of 73

Drug NameDrugTier Requirements/LimitsFOCALIN XR CP24 20MG 4 QL (60 EA per 30 days) PAINTUNIV 4METADATE CD CPCR 60MG 4 QL (30 EA per 30 days) PAMETADATE CD CPCR 10MG, 20MG 4 QL (60 EA per 30 days) PAmetadate er 1 PA MO GCmethylphenidate hcl 1 PA MO GCmethylphenidate hcl cd cpcr 50mg, 60mg 2 QL (30 EA per 30 days) PA MO GCmethylphenidate hcl cd cpcr 10mg 2 QL (60 EA per 30 days) MO GCmethylphenidate hcl er tbcr 20mg 1 PA MO GCmethylphenidate hydrochloride 2 PA MO GCSTRATTERA 4 QL (30 EA per 30 days) PACentral Nervous System, OtherNUEDEXTA 3 QL (60 EA per 30 days) MORILUTEK 5 PAXENAZINE 5 QL (124 EA per 25 days) PA LAFibromyalgia AgentsSAVELLA 3 QL (60 EA per 30 days) MOSAVELLA TITRATION PACK 3 QL (55 EA per 28 days) MOMultiple Sclerosis AgentsAMPYRA 5 QL (60 EA per 30 days) PA LAAUBAGIO 5 QL (30 EA per 30 days) PAAVONEX 5 QL (4 EA per 28 days) PABETASERON 5 QL (15 EA per 28 days) PACOPAXONE 5 QL (30 EA per 30 days) PAEXTAVIA 5 QL (15 EA per 28 days) PAGILENYA 5 QL (28 EA per 28 days) PAREBIF 5 QL (6 ML per 28 days) PAREBIF TITRATION PACK 5 QL (4.2 ML per 28 days) PATYSABRI 5 PA LAPsychotherapeutic Agentsbupropion hcl xl 1 MO GCDental and Oral AgentsDental and Oral Agentscevimeline hcl 2 MO GCchlorhexidine gluconate oral rinse 1 MO GCEVOXAC 4minocycline hcl 1 MO GCperiogard 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 36 of 73

Drug NameDrugTier Requirements/Limitspilocarpine hcl 2 MO GCpilocarpine hydrochloride 2 MO GCtriamcinolone in orabase 2 MO GCDermatological AgentsDermatological Agentsadapalene 2 PA MO GCammonium lactate 1 MO GCamnesteem 2 MO GCAZELEX 4betamethasone dipropionate 1 MO GCcalcipotriene crea 2 MO GCcalcipotriene oint, soln 2 MO GCCARAC 4CLARAVIS CAPS 30MG 5claravis caps 10mg, 20mg, 40mg 2 MO GCclindamycin/benzoyl peroxide gel 5%, 1% 2 MO GCclotrimazole/betamethasone dipropionate 1 MO GCCONDYLOX GEL 4CORTISPORIN 4DOVONEX 4ELIDEL 4 QL (100 GM per 30 days)erythromycin/benzoyl peroxide 2 MO GCFINACEA 4FLUOROPLEX 4fluorouracil external soln 2 MOfluorouracil crea, inj 2 MO GCimiquimod 1 MO GClaclotion 1 MO GCnystatin/triamcinolone 1 MO GCOXSORALEN ULTRA 4PHISOHEX 3 MOpodofilox 1 MO GCPROTOPIC OINT 0.03% 4 QL (100 GM per 30 days)PROTOPIC OINT 0.1% 4 QL (60 GM per 30 days)REGRANEX 5 QL (30 GM per 30 days) PASANTYL 4selenium sulfide lotn 2 MO GCSOLARAZE 4SORIATANE 5 QL (60 EA per 30 days) PAPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 37 of 73

Drug NameDrugTier Requirements/LimitsSTELARA 5 PATACLONEX 4TAZORAC 4VECTICAL 4VEREGEN 4VOLTAREN 4ZONALON 4ZYCLARA 4Enzyme Replacement/ ModifiersEnzyme Replacement/ ModifiersADAGEN 4ALDURAZYME 5 PA LABUPHENYL 5CARBAGLU 5 PACEREZYME 4CREON 3 MOFABRAZYME 5 PA LAKUVAN 5 PAMYOZYME 5 PANAGLAZYME 5 PA LAORFADIN 5PANCREAZE 4PERTZYE 4ULTRESA 5VIOKACE 4ZAVESCA 5ZENPEP 3 MOGastrointestinal AgentsAntispasmodics, Gastrointestinaldicyclomine hcl 1 PA MO GCglycopyrrolate inj 1 MO GCglycopyrrolate tabs 2 MO GCmethscopolamine bromide 2 MO GCGastrointestinal Agents, OtherCHENODAL 5diphenoxylate/atropine 1 PA MO GCloperamide hcl caps 1 MO GCRELISTOR INJ 12MG/0.6ML 4 QL (18 EA per 30 days) PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 38 of 73

Drug NameDrugTier Requirements/Limitsursodiol caps 1 MO GCursodiol tabs 2 MO GCGastrointestinal AgentsCOLYTE-FLAVOR PACKS 4gavilyte-c 1 MO GCgavilyte-g 1 MO GCgavilyte-n/flavor pack 1 MO GCGOLYTELY 4HELIDAC 4 QL (56 EA per 30 days)PREVPAC 4 QL (14 EA per 30 days)PYLERA 4 QL (120 EA per 30 days)trilyte 1 MO GCHistamine2 (H2) Receptor Antagonistscimetidine 1 MO GCcimetidine hcl soln 1 MO GCfamotidine inj, susr 1 MO GCfamotidine tabs 20mg, 40mg 1 MO GCnizatidine 1 MO GCranitidine hcl caps, syrp, tabs 1 MO GCIrritable Bowel Syndrome AgentsAMITIZA 4 QL (60 EA per 30 days) STbudesonide 2 MO GCLINZESS 4 QL (30 EA per 30 days) PALOTRONEX 3 QL (60 EA per 30 days) PA MOLaxativesconstulose 1 MO GCenulose 1 MO GCgenerlac 1 MO GCHALFLYTELY BOWEL PREP/FLAVOR PACKS 4KRISTALOSE 4lactulose 1 MO GCMOVIPREP 4polyethylene glycol 3350 powd 1 MO GCProtectantsCARAFATE SUSP 4misoprostol tabs 200mcg 1 MO GCsucralfate 1 MO GCProton Pump InhibitorsDEXILANT 4 QL (30 EA per 30 days) STPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 39 of 73

Drug NameDrugTier Requirements/Limitslansoprazole 2 QL (30 EA per 30 days) MO GCNEXIUM I.V. 4NEXIUM CPDR 3 QL (30 EA per 30 days) MONEXIUM PACK 10MG, 20MG, 40MG 3 QL (30 EA per 30 days) MOomeprazole cpdr 1 MO GCpantoprazole sodium tbec 1 MO GCGenitourinary AgentsAntispasmodics, UrinaryDETROL 4 QL (60 EA per 30 days)DETROL LA 4 QL (30 EA per 30 days)ENABLEX 3 QL (30 EA per 30 days) MOflavoxate hcl 1 MO GCGELNIQUE GEL 10% 4 QL (30 GM per 30 days)oxybutynin chloride 1 MO GCoxybutynin chloride er 1 MO GCOXYTROL 4 QL (8 EA per 28 days)SANCTURA XR 3 QL (30 EA per 30 days) MOtolterodine tartrate 2 QL (60 EA per 30 days) MO GCTOVIAZ 4 QL (30 EA per 30 days)trospium chloride 2 MO GCtrospium chloride er 2 QL (30 EA per 30 days) MO GCVESICARE 4 QL (30 EA per 30 days)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 MO GCAVODART 4 QL (30 EA per 30 days)finasteride tabs 5mg 1 MO GCJALYN 4 QL (30 EA per 30 days)RAPAFLO 3 QL (30 EA per 30 days) MOtamsulosin hcl 1 MO GCGenitourinary Agents, Otherbethanechol chloride 2 MO GCDEPEN TITRATABS 4ELMIRON 4potassium citrate 2 MO GCPhosphate Binderscalcium acetate caps 1 MO GCeliphos 2 MO GCFOSRENOL CHEW 1000MG, 500MG 5PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 40 of 73

Drug NameDrugTier Requirements/LimitsPHOSLYRA 4RENVELA TABS 4RENVELA PACK 2.4GM 5 QL (180 EA per 30 days)RENVELA PACK 0.8GM 5 QL (525 EA per 30 days)Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)Glucocorticoids/ Mineralocorticoidsa-hydrocort 2 MO GCalclometasone dipropionate 1 MO GCamcinonide 1 MO GCaugmented betamethasone dipropionate 1 MO GCbetamethasone dipropionate 1 MO GCbetamethasone valerate foam 1 MO GCbetamethasone valerate crea, lotn, oint 1 MO GCCAPEX 4CELESTONE 4clobetasol propionate e 1 MO GCclobetasol propionate gel, oint, soln 1 MO GCclobetasol propionate foam, lotn, sham 2 MO GCCORDRAN 4CORDRAN TAPE 4cortisone acetate 1 MO GCDERMA-SMOOTHE/FS BODY OIL 3 MODESONATE 4desonide crea 1 MO GCdesonide lotn, oint 2 MO GCDESOWEN 4desoximetasone crea, gel 2 MO GCdesoximetasone oint 0.05% 2 MO GCdesoximetasone oint 0.25% 2 MO GCdexamethasone 1 MO GCdexamethasone intensol 1 MO GCdexamethasone sodium phosphate 1 MO GCdiflorasone diacetate 2 MO GCfludrocortisone acetate 1 MO GCfluocinolone acetonide crea, oint, soln 1 MO GCfluocinolone acetonide oil 2 MO GCfluocinonide 1 MO GCfluocinonide-e 1 MO GCfluticasone propionate 1 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 41 of 73

Drug NameDrugTier Requirements/Limitshalobetasol propionate 1 MO GCHALOG 4hydrocortisone butyrate 2 MOhydrocortisone valerate 2 MO GChydrocortisone lotn, tabs 1 MO GChydrocortisone oint 2 MO GCKENALOG 4LOCOID LIPOCREAM 4methylprednisolone 1 MO GCmethylprednisolone acetate 1 MO GCmethylprednisolone dose pack 1 MO GCmethylprednisolone sodiumsuccinate inj 125mg, 40mg 1 MO GCmethylprednisolone sodiumsuccinate inj 1gm 1 MO GCMILLIPRED 3 MOmometasone furoate 1 MO GCORAPRED ODT 3 MOPANDEL 4prednicarbate 1 MO GCprednisolone sodium phosphate 1 MO GCprednisone 1 MO GCprednisone intensol 1 MO GCprocto-pak 1 MO GCproctozone-hc 1 MO GCSOLU-CORTEF INJ 100MG 3 MOSOLU-CORTEF INJ 250MG 4triamcinolone acetonide 1 MO GCu-cort 1 MO GCHormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)ACTHAR HP 5 PAHormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)desmopressin acetate 2 MO GCGENOTROPIN 5 ST PAGENOTROPIN MINIQUICK INJ 0.2MG 4 ST PAGENOTROPIN MINIQUICK INJ 0.4MG, 0.8MG, 1MG 5 ST PAHUMATROPE 5 ST PAINCRELEX 5 PANORDITROPIN FLEXPRO 5 PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 42 of 73

Drug NameDrugTier Requirements/LimitsNORDITROPIN NORDIFLEX PEN 5 PAnovarel 2 PA MONUTROPIN AQ PEN 5 ST PAOMNITROPE 4 PApregnyl w/diluent benzyl alcohol/nacl 2 PA MO GCSAIZEN CLICK.EASY 5 ST PATEV-TROPIN 5 ST PAHormonal Agents, Stimulant/ Replacement/ Modifying (SexHormones/ Modifiers)Anabolic SteroidsOXANDROLONE TABS 10MG 5 PAoxandrolone tabs 2.5mg 2 PA MO GCAndrogensANDRODERM 3 PA MOANDROGEL 3 PA MOANDROGEL PUMP 3 PA MOANDROXY 4danazol 2 MO GCMETHITEST 3 MOSTRIANT 4 QL (60 EA per 30 days) ST PAtestosterone cypionate 1 PA MO GCtestosterone enanthate 1 PA MO GCTESTRED 4 PAEstrogensALORA PTTW 0.05MG/24HR, 0.075MG/24HR,4 QL (8 EA per 28 days)0.1MG/24HRALORA PTTW 0.025MG/24HR 4 QL (8 EA per 30 days)CENESTIN 4 PADEPO-ESTRADIOL 4DIVIGEL 4ELESTRIN 4ENJUVIA TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG 4 QL (30 EA per 30 days)ENJUVIA TABS 1.25MG 4 QL (60 EA per 30 days)ESTRACE 4estradiol valerate 2 MO GCestradiol tabs 1 MO GCestradiol ptwk 0.025mg/24hr, 0.05mg/24hr, 0.06mg/24hr, 1 MO GC0.1mg/24hr, 37.5mcg/24hrestradiol ptwk 0.075mg/24hr 2 MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 43 of 73

Drug NameDrugTier Requirements/LimitsESTRING 4estropipate 1 PA MO GCEVAMIST 4FEMRING 4FEMTRACE TABS 0.9MG 4FEMTRACE TABS 0.45MG 4 QL (30 EA per 30 days)MENEST 4 PAMENOSTAR 4 QL (4 EA per 28 days)PREMARIN CREA 4PREMARIN TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG 4 QL (30 EA per 30 days) PAPREMARIN TABS 1.25MG 4 QL (60 EA per 30 days) PAVAGIFEM 4VIVELLE-DOT PTTW 0.05MG/24HR, 0.1MG/24HR 4 QL (8 EA per 28 days)VIVELLE-DOT PTTW 0.025MG/24HR, 0.0375MG/24HR 4 QL (8 EA per 30 days)Hormonal Agents, Stimulant/ Replacement/ Modifying (SexHormones/ Modifiers)amethia 2 MO GCamethyst 2 MO GCapri 1 MO GCaranelle 2 MO GCaviane 1 MO GCbalziva 2 MO GCbriellyn 2 MO GCCLIMARA PRO 4 QL (4 EA per 28 days)COMBIPATCH 4 QL (8 EA per 28 days)cryselle-28 1 MO GCcyclafem 1/35 1 MO GCcyclafem 7/7/7 1 MO GCemoquette 2 MO GCenpresse-28 1 MO GCestradiol/norethindrone acetate 2 MO GCFEMHRT LOW DOSE 4gianvi 1 MO GCintrovale 2 MO GCjinteli 1 MO GCjunel 1.5/30 1 MO GCjunel 1/20 1 MO GCjunel fe 1.5/30 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 44 of 73

Drug NameDrugTier Requirements/Limitszenchent fe 2 MO GCzeosa 2 MO GCzovia 1/35e 2 MO GCzovia 1/50e 2 MO GCProgestinscamila 1 MO GCCRINONE 4DEPO-PROVERA 4DEPO-SUBQ PROVERA 104 4errin 1 MO GCjolivette 1 MO GCmedroxyprogesterone acetate tabs 1 MO GCmedroxyprogesterone acetate inj 2 MO GCmegestrol acetate 1 MO GCnext choice 2 MO GCnora-be 1 MO GCnorethindrone acetate 2 MO GCprogesterone 2 MO GCSelective Estrogen Receptor Modifying AgentsEVISTA 3 QL (30 EA per 30 days) MOHormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)levothroid 1 MO GClevothyroxine sodium 1 MO GClevoxyl 1 MO GCliothyronine sodium 1 MO GCSYNTHROID 3 MOTIROSINT 4unithroid 1 MO GCHormonal Agents, Suppressant (Adrenal)Hormonal Agents, Suppressant (Adrenal)LYSODREN 3 MOHormonal Agents, Suppressant (Parathyroid)Hormonal Agents, Suppressant (Parathyroid)SENSIPAR 3 PA MOHormonal Agents, Suppressant (Pituitary)Hormonal Agents, Suppressant (Pituitary)cabergoline 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 46 of 73

Drug NameDrugTier Requirements/LimitsELIGARD INJ 22.5MG, 30MG, 7.5MG 4 PAELIGARD INJ 45MG 5 PAFIRMAGON INJ 120MG 5 PAleuprolide acetate 2 MO GCLUPRON DEPOT-PED INJ 11.25MG, 15MG 5 PALUPRON DEPOT INJ 22.5MG, 3.75MG, 30MG, 45MG, 5 PA7.5MGOCTREOTIDE ACETATE INJ 1000MCG/ML,5 PA200MCG/ML, 500MCG/MLoctreotide acetate inj 100mcg/ml, 50mcg/ml 2 PA MO GCSANDOSTATIN LAR DEPOT 5 PASOMATULINE DEPOT INJ 120MG/0.5ML, 60MG/0.2ML 5 PASOMAVERT 5 PA LASYNAREL 4 PATRELSTAR DEPOT MIXJECT 5 PATRELSTAR LA MIXJECT 5 PAHormonal Agents, Suppressant (Sex Hormones/ Modifiers)Antiandrogensbicalutamide 1 MO GCflutamide 1 MO GCNILANDRON 4ZYTIGA 5 QL (120 EA per 30 days) PAHormonal Agents, Suppressant (Thyroid)Antithyroid Agentsmethimazole 1 MO GCpropylthiouracil 1 MO GCImmunological AgentsImmune SuppressantsAFINITOR 5 QL (90 EA per 30 days) PAAZASAN TABS 75MG 4azathioprine 1 MO GCazathioprine sodium 2 MO GCCELLCEPT SUSR 4 PACIMZIA INJ 200MG/ML 5 QL (6 EA per 28 days) PAcyclosporine modified caps 50mg 2 B/D MO GCcyclosporine modified soln 2 B/D MO GCcyclosporine caps 2 B/D MO GCENBREL INJ 25MG 5 QL (16 EA per 28 days) PAENBREL INJ 50MG/ML 5 QL (200 ML per 28 days) PAPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 47 of 73

Drug NameDrugTier Requirements/LimitsENBREL INJ 25MG/0.5ML 5 QL (600 ML per 90 days) PAgengraf 2 B/D MO GCHUMIRA 5 QL (6 EA per 28 days) PAKINERET 5 QL (18.8 ML per 28 days) PAmercaptopurine 1 MO GCmethotrexate 1 MO GCmethotrexate sodium inj 25mg/ml 1 MO GCmycophenolate mofetil 2 PA MO GCMYFORTIC TBEC 180MG 4 B/DMYFORTIC TBEC 360MG 5 B/DORENCIA 5 PARAPAMUNE SOLN 5 B/DRAPAMUNE TABS 0.5MG 4 B/DRAPAMUNE TABS 1MG, 2MG 5 B/DREMICADE 5 PARHEUMATREX 4SIMPONI 5 QL (1 ML per 30 days) PATACROLIMUS CAPS 5MG 5 PAtacrolimus caps 0.5mg 2 B/D MO GCtacrolimus caps 1mg 2 PA MO GCTREXALL TABS 10MG, 15MG 4XELJANZ 5 QL (60 EA per 30 days) PAZORTRESS TABS 0.5MG, 0.75MG 5 PAImmunizing Agents, PassiveCARIMUNE NANOFILTERED INJ 3GM 5 B/DGAMASTAN S/D 4GAMMAGARD LIQUID 5 B/DImmunomodulatorsACTEMRA INJ 200MG/10ML 5 PAACTIMMUNE 5 PA LAARCALYST 5leflunomide 1 MO GCRIDAURA 4VaccinesACTHIB 3 MOADACEL 3 MOBOOSTRIX 4CERVARIX 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 48 of 73

Drug NameDrugTier Requirements/LimitsCOMVAX 4DAPTACEL 4DECAVAC 3 MOENGERIX-B INJ 10MCG/0.5ML, 20MCG/ML 3 B/D MOGARDASIL 4HAVRIX 3 MOIMOVAX RABIES (H.D.C.V.) 4INFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4M-M-R II W/DILUENT 10 DOSE 4MENACTRA 4MENOMUNE-A/C/Y/W-135 4MENVEO 4PEDVAX HIB 4PROQUAD 4RABAVERT 4RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML 4 B/DROTATEQ 4TETANUS TOXOID ADSORBED 3 MOTETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 3 MOTWINRIX 4TYPHIM VI 4VAQTA INJ 25UNIT/0.5ML 4VARIVAX 4YF-VAX 4ZOSTAVAX 4 QL (1 EA per 365 days)Inflammatory Bowel Disease AgentsAminosalicylatesAPRISO 3 MOASACOL 4ASACOL HD 4balsalazide disodium 2 MO GCCANASA 4DIPENTUM 4LIALDA 4mesalamine kit 2 MO GCPENTASA 4GlucocorticoidsPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 49 of 73

Drug NameDrugTier Requirements/Limitscolocort 2 MO GChydrocortisone 2 MO GCproctocream hc 1 MO GCSulfonamidessulfasalazine tabs 1 MO GCsulfazine ec 1 MO GCMetabolic Bone Disease AgentsMetabolic Bone Disease AgentsACTONEL TABS 150MG 4 QL (1 EA per 28 days) STACTONEL TABS 30MG, 5MG 4 QL (30 EA per 30 days) STACTONEL TABS 35MG 4 QL (4 EA per 30 days) STalendronate sodium 1 MO GCATELVIA 4 QL (4 EA per 28 days) STcalcitonin-salmon 2 MO GCcalcitriol caps 2 B/D MO GCetidronate disodium tabs 400mg 2 MO GCFORTEO 5 QL (2.4 ML per 30 days) PAFORTICAL 4FOSAMAX PLUS D 4 QL (4 EA per 28 days) STHECTOROL CAPS 4 ST B/Dibandronate sodium 2 QL (1 EA per 30 days) MO GCPAMIDRONATE DISODIUM INJ 6MG/ML 4 B/DPROLIA 4 QL (1 ML per 180 days) PARECLAST 4 B/DXGEVA 5 QL (5.1 ML per 90 days) PAZEMPLAR CAPS 1MCG, 2MCG 4 B/DZEMPLAR INJ 2MCG/ML 4 B/DZOMETA INJ 4MG/5ML 5 B/DOphthalmic AgentsOphthalmic Agents, OtherRESTASIS 4Ophthalmic Agentsbacitracin/polymyxin b 1 MO GCBLEPHAMIDE 4BLEPHAMIDE S.O.P. 4neomycin/bacitracin/polymyxin 1 MO GCneomycin/polymyxin/bacitracin/hydrocortisone 2 MO GCneomycin/polymyxin/dexamethasone 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 50 of 73

Drug NameDrugTier Requirements/Limitsneomycin/polymyxin/gramicidin 1 MO GCneomycin/polymyxin/hydrocortisone 2 MO GCPRED-G 3 MOsulfacetamide sodium 1 MO GCsulfacetamide sodium/prednisolone sodium phosphate 1 MO GCTOBRADEX ST 4tobramycin/dexamethasone 2 MO GCtrimethoprim sulfate/polymyxin b sulfate 1 MO GCZYLET 4Ophthalmic Anti-allergy AgentsALOCRIL 4ALOMIDE 4azelastine hcl 2 MO GCBEPREVE 4cromolyn sodium 1 MO GCELESTAT 4 STEMADINE 4epinastine hcl 2 MO GCLASTACAFT 4PATADAY 4PATANOL 4Ophthalmic Anti-inflammatoriesACUVAIL 4ALREX 4BROMDAY 3 MObromfenac 2 MO GCdexamethasone sodium phosphate 1 MO GCdiclofenac sodium 1 MO GCDUREZOL 4FLAREX 3 MOflurbiprofen sodium 1 MO GCFML 3 MOFML FORTE 3 MOketorolac tromethamine 1 MO GCLOTEMAX 4MAXIDEX 3 MOMILLIPRED 4NEVANAC 4ORAPRED ODT 4PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 51 of 73

Drug NameDrugTier Requirements/LimitsPRED MILD 3 MOprednisolone acetate 1 MO GCprednisolone sodium phosphate 1 MO GCVEXOL 3 MOOphthalmic Antiglaucoma AgentsALPHAGAN P SOLN 0.1% 4apraclonidine 2 MO GCAZOPT 4betaxolol hcl 2 MO GCBETIMOL 4BETOPTIC-S 4brimonidine tartrate 1 MO GCcarteolol hcl 1 MO GCCOMBIGAN 4dorzolamide hcl 1 MO GCdorzolamide hcl/timolol maleate 2 MO GCISTALOL 4levobunolol hcl soln 0.5% 1 MO GCmetipranolol 1 MO GCPHOSPHOLINE IODIDE 4PILOPINE HS 4timolol maleate 1 MO GCtimolol maleate ophthalmic gel forming 1 MO GCOphthalmic Prostaglandin and Prostamide Analogslatanoprost 1 MO GCLUMIGAN SOLN 0.03% 3 MOLUMIGAN SOLN 0.01% 3 PA MOTRAVATAN Z 3 MOOtic AgentsOtic Agentsacetasol hc 2 MO GCCIPRO HC 4CIPRODEX 4COLY-MYCIN S 4CORTISPORIN-TC 4DERMOTIC 4neomycin/polymyxin/hc 1 MO GCneomycin/polymyxin/hydrocortisone otic susp 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 52 of 73

Drug NameDrugTier Requirements/LimitsRespiratory Tract AgentsAnti-inflammatories, Inhaled CorticosteroidsALVESCO 4ASMANEX 120 METERED DOSES 4ASMANEX 30 METERED DOSES AEPB 110MCG/INH 4budesonide 2 B/D MO GCFLOVENT DISKUS 4FLOVENT HFA 4flunisolide soln 0.025% 2 MO GCfluticasone propionate 2 MO GCNASONEX 3 MOPULMICORT FLEXHALER 4QVAR 4RHINOCORT AQUA 4 STtriamcinolone acetonide 2 MO GCVERAMYST 4 STAntihistaminesASTEPRO 3 MOazelastine hcl 2 MO GCcarbinoxamine maleate 1 MO GCcetirizine hcl syrp 1 MO GCcyproheptadine hcl 1 PA MO GCdesloratadine 2 MOdesloratadine odt 2 MOlevocetirizine dihydrochloride tabs 1 MO GCPATANASE 4Antileukotrienesmontelukast sodium chew, tabs 2 QL (30 EA per 30 days) MOSINGULAIR 3 QL (30 EA per 30 days) MOzafirlukast 2 MO GCZYFLO CR 4 QL (120 EA per 30 days)Antitussiveshydrocodone bitartrate/homatropine methylbromide 1 QL (180 ML per 31 days) MO GCEDpromethazine vc/codeine 1 QL (180 ML per 31 days) MO GCEDpromethazine/codeine 1 QL (180 ML per 31 days) MO GCEDPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 53 of 73

Drug NameDrugTier Requirements/Limitspromethazine/dextromethorphan 1 QL (180 ML per 31 days) MO GCEDBronchodilators, AnticholinergicATROVENT HFA 4ipratropium bromide inhalation soln 1 B/D MO GCipratropium bromide nasal soln 1 MO GCSPIRIVA HANDIHALER 3 MOTUDORZA PRESSAIR 4 QL (60 EA per 30 days)Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)aminophylline 1 MO GCELIXOPHYLLIN 4LUFYLLIN 4theophylline cr 1 MO GCtheophylline er tb24 1 MO GCtheophylline er tb12 300mg, 450mg 1 MO GCBronchodilators, Sympathomimeticalbuterol sulfate er tb12 8mg 1 MO GCalbuterol sulfate er tb12 4mg 2 MO GCalbuterol sulfate syrp, tabs 1 MO GCalbuterol sulfate nebu 0.083%, 0.5% 1 B/D MO GCalbuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml 2 B/D MO GCARCAPTA NEOHALER 4BROVANA 4 B/DDULERA 4 QL (13 GM per 25 days)epinephrine hcl inj 0.1mg/ml 1 MO GCEPIPEN 2-PAK 4 QL (2 EA per 30 days)EPIPEN-JR 2-PAK 4 QL (2 EA per 30 days)FORADIL AEROLIZER 4 QL (60 EA per 30 days)levalbuterol 1.25 MG/0.5ML 2 B/D MO GCMAXAIR AUTOHALER 4metaproterenol sulfate syrp 1 MO GCPERFOROMIST 4 B/DPROAIR HFA 4PROVENTIL HFA 4SEREVENT DISKUS 4 QL (60 EA per 30 days)terbutaline sulfate 1 MO GCTWINJECT INJ 0.3MG/0.3ML 4 QL (4 EA per 30 days)VENTOLIN HFA 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 54 of 73

Drug NameDrugTier Requirements/LimitsXOPENEX HFA 4Mast Cell Stabilizerscromolyn sodium nebu 2 B/D MO GCPulmonary AntihypertensivesADCIRCA 5 QL (60 EA per 30 days) PALETAIRIS 5 QL (30 EA per 30 days) PA LAREVATIO TABS 5 QL (90 EA per 30 days) PASILDENAFIL CITRATE 5 QL (90 EA per 30 days) PATRACLEER TABS 62.5MG 5 QL (120 EA per 30 days) PA LATRACLEER TABS 125MG 5 QL (60 EA per 30 days) PA LAVENTAVIS SOLN 10MCG/ML 5 PARespiratory Tract Agents, Otheracetylcysteine soln 2 B/D MO GCARALAST NP INJ 400MG 5 PA LAKALYDECO 5 PAPROLASTIN-C 5 PA LATYZINE 3 MOTYZINE PEDIATRIC NASAL DROPS 3 MOZEMAIRA 5 PA LARespiratory Tract AgentsADVAIR DISKUS 4 QL (60 EA per 30 days)ADVAIR HFA 4 QL (60 GM per 30 days)COMBIVENT 4COMBIVENT RESPIMAT 4 QL (8 GM per 30 days)DALIRESP 4ipratropium bromide/albuterol sulfate 2 B/D MO GCpromethazine vc 1 PA MO GCPULMOZYME 5 PASYMBICORT 3 QL (11 GM per 30 days) MOXOLAIR 5 PA LASkeletal Muscle RelaxantsSkeletal Muscle Relaxantscarisoprodol tabs 350mg 2 PA MO GCchlorzoxazone 2 PA MO GCcyclobenzaprine hcl er 2 PA MO GCcyclobenzaprine hcl tabs 10mg, 5mg 2 PA MO GCLORZONE 3 PA MOmethocarbamol 2 PA MO GCorphenadrine citrate 2 PA MO GCPA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 55 of 73

Drug NameDrugTier Requirements/Limitsorphenadrine citrate er 2 PA MO GCsoma tabs 250mg 2 MO GCtizanidine hcl 2 MO GCSleep Disorder AgentsGABA Receptor ModulatorsLUNESTA 4 QL (30 EA per 30 days) STzaleplon 1 QL (30 EA per 30 days) MO GCzolpidem tartrate 1 QL (30 EA per 30 days) MO GCzolpidem tartrate er 2 QL (30 EA per 30 days) MO GCSleep Disorders, Othermodafinil 2 PA MONUVIGIL 4 QL (30 EA per 30 days) PAROZEREM 4 QL (30 EA per 30 days) STXYREM 5 QL (540 ML per 30 days) PA LATherapeutic Nutrients/ Minerals/ ElectrolytesElectrolyte/ Mineral ModifiersEXJADE 5 PA LAkionex 2 MO GCSAMSCA 5 PAElectrolyte/ Mineral Replacementklor-con 10 1 MO GCklor-con 8 1 MO GCKLOR-CON M15 3 MOklor-con m20 1 MO GCOSMOPREP 4PLASMA-LYTE-148 4potassium chloride 1 MO GCpotassium chloride 0.15% /nacl 0.45% viaflex 1 MO GCpotassium chloride 0.15% nacl 0.9% 1 MO GCpotassium chloride er 1 MO GCsodium chloride 1 MO GCsodium chloride 0.45% viaflex 1 MO GCsodium chloride 0.9% 1 MO GCSUPREP BOWEL PREP 4Therapeutic Nutrients/ Minerals/ ElectrolytesAMINOSYN II 3 B/D MOAMINOSYN M 3 B/D MOAMINOSYN-HBC 3 B/D MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 56 of 73

Drug NameDrugTier Requirements/LimitsAMINOSYN-PF 3 B/D MOAMINOSYN-PF 7% 3 B/D MOCLINIMIX 2.75%/DEXTROSE 5% 3 B/D MOCLINIMIX 4.25%/DEXTROSE 10% 3 B/D MOCLINIMIX 4.25%/DEXTROSE 20% 3 B/D MOCLINIMIX 4.25%/DEXTROSE 25% 3 B/D MOCLINIMIX 4.25%/DEXTROSE 5% 3 B/D MOCLINIMIX 5%/DEXTROSE 15% 3 B/D MOCLINIMIX 5%/DEXTROSE 20% 3 B/D MOCLINIMIX 5%/DEXTROSE 25% 3 B/D MOCLINIMIX E 2.75%/DEXTROSE 10% 3 B/D MOCLINIMIX E 2.75%/DEXTROSE 5% 3 B/D MOCLINIMIX E 4.25%/DEXTROSE 25% 3 B/D MOCLINIMIX E 4.25%/DEXTROSE 5% 3 B/D MOCLINIMIX E 5%/DEXTROSE 15% 3 B/D MOCLINIMIX E 5%/DEXTROSE 20% 3 B/D MOCLINIMIX E 5%/DEXTROSE 25% 3 B/D MOCLINISOL SF 15% 4 B/Ddextrose 10% flex container 1 MO GCdextrose 10%/nacl 0.2% 1 MO GCdextrose 2.5%/sodium chloride 0.45% 1 MO GCdextrose 5% 1 MO GCDEXTROSE 5%/LACTATED RINGERS 4dextrose 5%/nacl 0.2% 1 MO GCdextrose 5%/nacl 0.33% 1 MO GCdextrose 5%/nacl 0.45% 1 MO GCdextrose 5%/nacl 0.9% 1 MO GCdextrose 5%/potassium chloride 0.15% 1 MO GCFREAMINE III 3% 3 B/D MOHEPATASOL 3 B/D MOintralipid 1 B/D MO GCIONOSOL-B/DEXTROSE 5% 4ISOLYTE-P/DEXTROSE 5% 4kcl 0.075%/d5w/nacl 0.45% 1 MO GCKCL 0.15%/D5W/LR 4kcl 0.15%/d5w/nacl 0.2% 1 MO GCkcl 0.15%/d5w/nacl 0.9% 1 MO GCkcl 0.3%/d5w/nacl 0.45% 1 MO GCKCL 0.3%/D5W/NACL 0.9% 4PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coveragefor this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage. GC D = Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription maybe available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or callMember Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.MO = Mail Order: This prescription may be available through mail-order service, please refer to our Evidence ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. However, Simply Healthcare Plans, Inc. does provide supplemental coverage for thesemedications. The amount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you arereceiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 57 of 73

Drug NameDrugTier Requirements/Limitslactated ringers irrigation 2 MO GClactated ringers viaflex 2 MO GClevocarnitine 2 B/D MO GCNEPHRAMINE 3 B/D MOnormosol-m in d5w 1 MO GCnormosol-r in d5w 1 MO GCPLASMA-LYTE-56/D5W 4potassium chloride 0.15% d5w/nacl 0.33% 1 MO GCpotassium chloride 0.15% d5w/nacl 0.45% viaflex 1 MO GCpotassium chloride 0.22% d5w/nacl 0.45% 1 MO GCpotassium chloride 0.224%/dextrose 5% viaflex 1 MO GCpotassium chloride 0.3%/d5w 1 MO GCPREMASOL 3 B/D MOPROCALAMINE 3 B/D MOPROSOL 3 B/D MOsterile water irrigation 1 MO GCTRAVASOL 4 B/DVitaminsVitamin B Complexfolic acid 1 MO GC EDVitamin Dergocalciferol 1 QL (4 EA per 31 days) MO GC EDPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha paracierto planes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea másinformación, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliadosllamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido porcorreo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados deMedicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en sucosto total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura porcatástrofe). Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo deayuda adicional para pagar este medicamento. Page 58 of 73

IndexAabacavir.....................................22abelcet.......................................14abilify discmelt tbdp 10mg .......21abilify discmelt tbdp 15mg .......21abilify inj ..................................21abilify oral soln.........................21abilify tabs 10mg, 15mg, 2mg, 5mg..............................................21abilify tabs 20mg, 30mg ...........21abstral subl 100mcg....................3abstral subl 200mcg, 800mcg .....3acarbose ....................................25acebutolol hcl............................31acetaminophen/caffeine/dihydrocodeinebitartrate .................................1acetaminophen/codeine #3 .........1acetaminophen/codeine soln.......1acetaminophen/codeine tabs 300mg,15mg.......................................1acetaminophen/codeine tabs 300mg,60mg.......................................1acetasol hc ................................52acetazolamide ...........................33acetazolamide er .......................33acetic acid ...................................5acetylcysteine soln....................55actemra inj 200mg/10ml...........48acthar hp ...................................42acthib ........................................48actimmune ................................48actonel tabs 150mg ...................50actonel tabs 30mg, 5mg............50actonel tabs 35mg .....................50actoplus met..............................27actoplus met xr..........................27actos..........................................25acuvail.......................................51acyclovir ...................................24acyclovir sodium inj 500mg .....24aczone.......................................16adacel........................................48adagen.......................................38adapalene ..................................37adcirca.......................................55adderall xr cp24 1.25mg, 1.25mg,1.25mg, 1.25mg....................35adderall xr cp24 2.5mg, 2.5mg, 2.5mg,2.5mg, 3.75mg, 3.75mg, 3.75mg,3.75mg, 5mg, 5mg, 5mg, 5mg,6.25mg, 6.25mg, 6.25mg, 6.25mg,7.5mg, 7.5mg, 7.5mg, 7.5mg35adriamycin inj 2mg/ml..............17advair diskus.............................55advair hfa..................................55advicor tb24 20mg, 1000mg, 20mg,500mg, 20mg, 750mg...........32advicor tb24 40mg, 1000mg.....32afeditab cr .................................31afinitor ................................18, 47afinitor tabs 10mg.....................18afinitor tabs 5mg.......................18afinitor tabs 7.5mg....................18aggrenox ...................................29a-hydrocort ...............................41akne-mycin .................................8albenza......................................19albuterol sulfate er tb12 4mg ....54albuterol sulfate er tb12 8mg ....54albuterol sulfate nebu 0.083%, 0.5%..............................................54albuterol sulfate nebu 0.63mg/3ml,1.25mg/3ml ..........................54albuterol sulfate syrp, tabs........54alclometasone dipropionate ......41Alcohol Deterrents/ Anti-craving4alcohol preps pads ......................5aldactazide ................................32aldurazyme ...............................38alendronate sodium...................50alfuzosin hcl er..........................40alimta ........................................17alinia tabs..................................19Alkylating Agents.....................16allopurinol.................................15alocril........................................51alomide .....................................51alora pttw 0.025mg/24hr...........43alora pttw 0.05mg/24hr, 0.075mg/24hr,0.1mg/24hr ...........................43aloxi ..........................................13Alpha-adrenergic Agonists.......29Alpha-adrenergic Blocking Agents..............................................29alphagan p soln 0.1%................52alprazolam er tb24 0.5mg .........24alprazolam intensol...................24alprazolam odt tbdp 0.25mg, 0.5mg..............................................24alprazolam odt tbdp 1mg, 2mg .25alprazolam tabs 0.25mg, 0.5mg25alprazolam tabs 1mg, 2mg........25alprazolam xr tb24 1mg, 2mg, 3mg..............................................25alrex ..........................................51altabax.........................................5alvesco ......................................53amantadine hcl..........................20ambisome..................................14amcinonide ...............................41amethia .....................................44amethyst....................................44amifostine .................................17amikacin sulfate inj 1gm/4ml .....5amiloride hcl.............................33amiloride/hydrochlorothiazide..32Aminoglycosides ........................5aminophylline...........................54Aminosalicylates ......................49aminosyn ii ...............................56aminosyn m ..............................56aminosyn-hbc ...........................56aminosyn-pf..............................57aminosyn-pf 7%........................57amiodarone hcl tabs 400mg......30amitiza ......................................39amitriptyline hcl........................13amlodipine besylate............31, 32amlodipine besylate/benazepril hcl..............................................32amlodipine besylate/benazeprilhydrochloride .......................32ammonium lactate ....................37amnesteem ................................37amoxapine tabs 100mg, 25mg, 50mg..............................................13amoxicillin caps, susr, tabs.........7amoxicillin chew 250mg ............7amoxicillin/clavulanate potassium chew................................................7amoxicillin/clavulanate potassium er................................................7amoxicillin/clavulanate potassium susr250mg/5ml, 62.5mg/5ml,400mg/5ml, 57mg/5ml, 600mg/5ml,42.9mg/5ml ............................7amoxicillin/clavulanate potassium tabs250mg, 125mg........................7amoxicillin/potassium clavulanate susr200mg/5ml, 28.5mg/5ml........7amoxicillin/potassium clavulanate tabs................................................7amphetamine/dextroamphetamine cp24..............................................35amphetamine/dextroamphetamine tabs..............................................35amphotec inj 50mg ...................14amphotericin b..........................14ampicillin caps............................7ampicillin sodium inj 125mg, 1gm................................................759

ampicillin-sulbactam inj 10gm, 5gm,2gm, 1gm................................7ampyra ......................................36amturnide..................................32Anabolic Steroids .....................43anagrelide hydrochloride ..........29Analgesics...........................1, 3, 4anastrozole................................18ancobon.....................................14androderm.................................43androgel ....................................43androgel pump ..........................43Androgens.................................43androxy.....................................43Anesthetics .................................4Angiotensin II Receptor Antagonists..............................................30Angiotensin-converting Enzyme (ACE)Inhibitors ..............................30antara ........................................34Anthelmintics............................19Anti-Addiction/ Substance AbuseTreatment Agents ...................4Antiandrogens...........................47Antiangiogenic Agents .............17Antiarrhythmics........................30Antibacterials..........................5, 6Antibacterials, Other...................5Anticholinergics........................20Anticoagulants..........................28Anticonvulsants ..........................9Anticonvulsants, Other ...............9Anti-cytomegalovirus (CMV) Agents..............................................22Antidementia Agents ................11Antidementia Agents, Other.....11Antidepressants...................11, 12Antidepressants, Other..............11Antidiabetic Agents ..................25Antiemetics...............................13Antiemetics, Other....................13Antiestrogens/Modifiers ...........17Antifungals ...............................14Antigout Agents........................15Antihepatitis Agents .................23Antiherpetic Agents..................24Antihistamines..........................53Anti-HIV Agents, Non-nucleosideReverse Transcriptase Inhibitors..............................................22Anti-HIV Agents, Nucleoside andNucleotide Reverse TranscriptaseInhibitors ..............................22Anti-HIV Agents, Other ...........23Anti-HIV Agents, Protease Inhibitors..............................................23Anti-inflammatories, InhaledCorticosteroids .....................53Anti-inflammatory Agents..........5Anti-influenza Agents...............23Antileukotrienes........................53Antimetabolites.........................17Antimigraine Agents.................15Antimyasthenic Agents.............16Antimycobacterials...................16Antimycobacterials, Other........16Antineoplastics ...................16, 17Antineoplastics, Other ..............17Antiparasitics............................19Antiparkinson Agents...............20Antiparkinson Agents, Other....20Antiprotozoals ..........................19Antipsychotics ..........................20Antispasmodics, Gastrointestinal38Antispasmodics, Urinary ..........40Antispasticity Agents................22Antithyroid Agents ...................47Antituberculars .........................16Antitussives ..............................53Antivirals ............................22, 24Anxiolytics ...............................24Anxiolytics, Other ....................24apidra ........................................27apidra solostar...........................27aplenzin.....................................11apokyn ......................................20apraclonidine ............................52apri............................................44apriso ........................................49aptivus caps ..............................23aptivus soln...............................23aralast np inj 400mg .................55aranelle .....................................44aranesp albumin free inj 100mcg/ml..............................................29aranesp albumin free inj 200mcg/ml..............................................29aranesp albumin free inj 25mcg/ml..............................................29aranesp albumin free inj 300mcg/0.6ml..............................................29aranesp albumin free inj 40mcg/ml..............................................29aranesp albumin free inj 500mcg/ml..............................................29aranesp albumin free inj 60mcg/ml..............................................29arcalyst......................................48arcapta neohaler........................54Aromatase Inhibitors, 3rd Generation..............................................18arranon......................................17arthrotec 50.................................1arthrotec 75.................................1arzerra inj 100mg/5ml ..............19asacol ........................................49asacol hd ...................................49ascomp/codeine ..........................1asmanex 120 metered doses .....53asmanex 30 metered doses aepb110mcg/inh...........................53astepro.......................................53astramorph ..................................3atelvia .......................................50atenolol ...............................31, 32atenolol/chlorthalidone .............32atorvastatin calcium..................34atovaquone/proguanil hcl tabs 250mg,100mg...................................19atripla........................................24atrovent hfa...............................54Attention Deficit HyperactivityDisorder Agents, Amphetamines..............................................35Attention Deficit HyperactivityDisorder Agents, Non-amphetamines..............................................35aubagio .....................................36augmented betamethasone dipropionate..............................................41avandamet.................................27avandaryl ..................................27avandia tabs 2mg, 4mg .............25avandia tabs 8mg ......................25avastin.......................................17avelox .........................................8aviane........................................44avodart ......................................40avonex.......................................36axert tabs 12.5mg......................16azasan tabs 75mg......................47azasite .........................................8azathioprine ..............................47azathioprine sodium..................47azelastine hcl ......................51, 53azelex........................................37azilect........................................20azithromycin inj 500mg..............8azithromycin susr, tabs ...............8azopt .........................................52azor ...........................................32aztreonam inj 1gm ......................7bacitracin oint .............................560B

acitracin/polymyxin b.............50baclofen ....................................22bactroban crea.............................5bactroban nasal ...........................5balsalazide disodium.................49balziva.......................................44banzel susp................................10banzel tabs 200mg ....................10banzel tabs 400mg ....................10baraclude soln...........................24baraclude tabs 0.5mg ................24baraclude tabs 1mg ...................24bd insulin syringe safetyglide/1ml/29gx 1/2......................................27bd insulin syringe ultrafine/0.3ml/31g x5/16.......................................27bd insulin syringe ultrafine/0.5ml/30g x1/2.........................................27bd insulin syringe ultrafine/1ml/31g x5/16.......................................27bd pen needle/ultrafine/29g x 12.7mm..............................................27benazepril hcl......................30, 32benazepril hcl/hydrochlorothiazide..............................................32benicar ................................30, 32benicar hct ................................32Benign Prostatic Hypertrophy Agents..............................................40benztropine mesylate ................20bepreve .....................................51besivance ....................................8Beta-adrenergic Blocking Agents31Beta-lactam, Cephalosporins ......6Beta-lactam, Other......................7Beta-lactam, Penicillins..............7betamethasone dipropionate37, 41betamethasone valerate crea, lotn, oint..............................................41betamethasone valerate foam....41betaseron...................................36betaxolol hcl .......................31, 52betaxolol hcl tabs 10mg............31betaxolol hcl tabs 20mg............31bethanechol chloride.................40betimol......................................52betoptic-s ..................................52bicalutamide..............................47bicillin c-r inj 300000unit/ml,300000unit/ml ........................7bicillin l-a....................................7biltricide....................................19Bipolar Agents..........................25bisoprolol fumarate.............31, 32bisoprololfumarate/hydrochlorothiazide32blephamide ...............................50blephamide s.o.p.......................50Blood Formation Modifiers......28Blood Glucose Regulators..25, 27Blood Products/ Modifiers/ VolumeExpanders.......................28, 29boostrix.....................................48bosulif.......................................18botox inj 100unit.......................16briellyn......................................44brimonidine tartrate ..................52bromday....................................51bromfenac.................................51bromocriptine mesylate ............20Bronchodilators, Anticholinergic54Bronchodilators, PhosphodiesteraseInhibitors (Xanthines) ..........54Bronchodilators, Sympathomimetic..............................................54brovana .....................................54budeprion sr..............................11budesonide..........................39, 53bumetanide ...............................33buphenyl ...................................38buprenorphine hcl.......................4buproban...................................11bupropion hcl......................11, 36bupropion hcl sr tb12 200mg....11bupropion hcl xl........................36buspirone hcl tabs 10mg, 15mg, 30mg,5mg.......................................25buspirone hcl tabs 7.5mg..........25butalbital/acetaminophen/caffeine/codeine............................................1butorphanol tartrate inj 2mg/ml..4butorphanol tartrate nasal soln....4butrans ptwk 10mcg/hr, 20mcg/hr1butrans ptwk 5mcg/hr .................1bydureon...................................26byetta inj 10mcg/0.04ml ...........26byetta inj 5mcg/0.02ml .............26bystolic tabs 10mg....................31bystolic tabs 2.5mg...................31bystolic tabs 20mg....................31bystolic tabs 5mg......................31Ccabergoline ...............................46calcipotriene crea......................37calcipotriene oint, soln..............37calcitonin-salmon......................50calcitriol caps............................50calcium acetate caps .................40Calcium Channel Blocking Agents..............................................31Calcium Channel Modifying Agents................................................9camila .......................................46campath.....................................17campral .......................................4canasa .......................................49cancidas inj 70mg .....................14candesartancilexetil/hydrochlorothiazide32capex.........................................41caprelsa tabs 100mg..................18caprelsa tabs 300mg..................19captopril..............................30, 32captopril/hydrochlorothiazide...32carac..........................................37carafate susp .............................39carbaglu ....................................38carbamazepine chew, susp........10carbamazepine er................10, 25carbidopa/levodopa...................20carbidopa/levodopa er...............20carbinoxamine maleate.............53carboplatin inj 150mg/15ml......17Cardiovascular Agents........29, 32Cardiovascular Agents, Other...32Cardiovascular Drugs ...............35carimune nanofiltered inj 3gm..48carisoprodol tabs 350mg...........55carisoprodol/aspirin ....................1carisoprodol/aspirin/codeine.......1carteolol hcl ..............................52cartia xt .....................................31carvedilol ..................................31cayston........................................7ceenu.........................................16cefaclor caps ...............................6cefadroxil....................................6cefazolin sodium inj 10gm, 1gm,500mg.....................................6cefdinir........................................6cefepime inj 1gm, 2gm ...............6cefotaxime sodium inj 10gm, 1gm, 2gm................................................6cefotetan .....................................6cefoxitin sodium inj 1gm, 4%, 2gm................................................6cefpodoxime proxetil..................6cefprozil......................................7ceftazidime inj 1gm, 2gm ...........7ceftriaxone sodium inj 10gm, 250mg,500mg.....................................7cefuroxime axetil tabs.................7cefuroxime sodium inj 1.5gm, 7.5gm,750mg.....................................761

celebrex caps 100mg ..................2celebrex caps 200mg, 400mg, 50mg................................................2celestone ...................................41cellcept susr ..............................47celontin .......................................9cenestin.....................................43Central Nervous System Agents35Central Nervous System, Other 36cephalexin caps, susr ..................7cerezyme...................................38cervarix.....................................48cetirizine hcl syrp......................53cevimeline hcl...........................36chantix starting month pak .........5chantix tabs 0.5mg......................5chantix tabs 1mg.........................5chenodal....................................38chlordiazepoxide/amitriptyline.12chlorhexidine gluconate oral rinse36chloroquine phosphate..............19chlorothiazide ...........................33chlorpromazine hcl ...................13chlorpropamide tabs 100mg .....26chlorpropamide tabs 250mg .....26chlorthalidone tabs 25mg, 50mg33chlorzoxazone...........................55cholestyramine light pack.........34Cholinesterase Inhibitors ..........11cialis..........................................35ciclopirox..................................14ciclopirox nail lacquer ..............14ciclopirox olamine ....................14cidofovir ...................................22cilostazol...................................29ciloxan oint .................................8cimetidine .................................39cimetidine hcl soln....................39cimzia inj 200mg/ml.................47cinryze ......................................29cipro hc .....................................52cipro susr 500mg/5ml .................8ciprodex ....................................52ciprofloxacin er...........................8ciprofloxacin hcl.........................8ciprofloxacin inj 400mg/40ml ....8citalopram hydrobromide .........12claravis caps 10mg, 20mg, 40mg37claravis caps 30mg....................37clarithromycin.............................8clarithromycin er.........................8cleocin pediatric granules ...........5cleocin supp................................5climara pro................................44clindamycin hcl caps 150mg, 300mg................................................5clindamycin phosphate add-vantage................................................5clindamycin phosphate crea, gel, lotn,soln, swab...............................5clindamycin phosphate foam......5clindamycin/benzoyl peroxide gel 5%,1% ........................................37clinimix 2.75%/dextrose 5%.....57clinimix 4.25%/dextrose 10%...57clinimix 4.25%/dextrose 20%...57clinimix 4.25%/dextrose 25%...57clinimix 4.25%/dextrose 5%.....57clinimix 5%/dextrose 15%........57clinimix 5%/dextrose 20%........57clinimix 5%/dextrose 25%........57clinimix e 2.75%/dextrose 10%57clinimix e 2.75%/dextrose 5%..57clinimix e 4.25%/dextrose 25%57clinimix e 4.25%/dextrose 5%..57clinimix e 5%/dextrose 15%.....57clinimix e 5%/dextrose 20%.....57clinimix e 5%/dextrose 25%.....57clinisol sf 15% ..........................57clobetasol propionate e .............41clobetasol propionate foam, lotn, sham..............................................41clobetasol propionate gel, oint, soln..............................................41clomipramine hcl ......................13clonazepam odt tbdp 0.125mg, 0.25mg,0.5mg, 1mg...........................25clonazepam odt tbdp 2mg.........25clonazepam tabs 0.5mg, 1mg ...25clonazepam tabs 2mg................25clonidine hcl ptwk ....................29clonidine hcl tabs......................29clopidogrel tabs 300mg ............29clopidogrel tabs 75mg ..............29clorazepate dipotassium............25clorpres .....................................32clotrimazole soln, troc ..............14clotrimazole/betamethasonedipropionate..........................37clozapine...................................22Coagulants ................................29codeine sulfate tabs 30mg...........4codeine sulfate tabs 60mg...........4co-gesic.......................................1colcrys.......................................15colestipol hcl.............................34colistimethate sodium.................6colocort.....................................50coly-mycin s .............................52colyte-flavor packs ...................39combigan ..................................52combipatch ...............................44combivent .................................55combivent respimat ..................55cometriq....................................17complera ...................................22compro......................................13comtan ......................................20comvax .....................................49condylox gel .............................37constulose .................................39copaxone...................................36cordran......................................41cordran tape ..............................41coreg cr .....................................31cortisone acetate .......................41cortisporin...........................37, 52cortisporin-tc.............................52coumadin ..................................28creon .........................................38crestor .......................................34crinone ......................................46crixivan caps 400mg.................23cromolyn sodium................51, 55cromolyn sodium nebu .............55cryselle-28 ................................44cubicin ........................................6curity gauze pads 2 ...................27cyclafem 1/35 ...........................44cyclafem 7/7/7 ..........................44cyclobenzaprine hcl er..............55cyclobenzaprine hcl tabs 10mg, 5mg..............................................55cyclophosphamide tabs.............16cycloset.....................................26cyclosporine caps......................47cyclosporine modified caps 50mg47cyclosporine modified soln.......47cymbalta cpep 20mg, 30mg......12cymbalta cpep 60mg.................12cyproheptadine hcl....................53cytarabine aqueous ...................17Ddacogen.....................................17daliresp .....................................55danazol......................................43dantrolene sodium caps ............22dapsone.....................................16daptacel.....................................49daraprim....................................19daytrana ....................................35decavac .....................................49demeclocycline hcl .....................9denavir ......................................2462

Dental and Oral Agents ............36depen titratabs...........................40depo-estradiol ...........................43depo-provera.............................46depo-subq provera 104 .............46derma-smoothe/fs body oil .......41Dermatological Agents.............37dermotic....................................52desipramine hcl.........................13desloratadine.............................53desloratadine odt.......................53desmopressin acetate ................42desonate ....................................41desonide crea ............................41desonide lotn, oint.....................41desowen ....................................41desoximetasone crea, gel ..........41desoximetasone oint 0.05% ......41desoximetasone oint 0.25% ......41detrol.........................................40detrol la.....................................40dexamethasone....................41, 51dexamethasone intensol............41dexamethasone sodium phosphate41,51dexilant .....................................39dexmethylphenidate hcl............35dexrazoxane inj 500mg.............17dextroamphetamine sulfate.......35dextroamphetamine sulfate er...35dextrose 10% flex container .....57dextrose 10%/nacl 0.2% ...........57dextrose 2.5%/sodium chloride 0.45%..............................................57dextrose 5% ..............................57dextrose 5%/lactated ringers.....57dextrose 5%/nacl 0.2% .............57dextrose 5%/nacl 0.33% ...........57dextrose 5%/nacl 0.45% ...........57dextrose 5%/nacl 0.9% .............57dextrose 5%/potassium chloride 0.15%..............................................57diazepam gel.............................25diazepam soln ...........................25diazepam tabs 10mg .................25diazepam tabs 2mg, 5mg ..........25dibenzyline ...............................29diclofenac potassium ..................2diclofenac sodium.................2, 51diclofenac sodium dr ..................2diclofenac sodium er...................2diclofenac sodium/misoprostol...2dicloxacillin sodium ...................7dicyclomine hcl.........................38didanosine.................................22dificid..........................................8diflorasone diacetate.................41diflunisal.....................................2digoxin soln, tabs......................32dihydroergotamine mesylate.....15dilantin................................10, 11dilantin infatabs ........................11dilatrate sr .................................35dilaudid-5....................................4dilt-cd cp24 120mg, 300mg......31diltiazem cd cp24 120mg, 240mg,300mg...................................31diltiazem hcl er cp12.................31diltiazem hcl er cp24 180mg, 360mg..............................................31diltiazem hcl tabs......................31dilt-xr cp24 180mg, 240mg ......31diovan .......................................30dipentum...................................49diphenhydramine hcl caps 50mg13diphenoxylate/atropine .............38dipyridamole.............................29disopyramide phosphate ...........30disulfiram....................................4Diuretics, Carbonic AnhydraseInhibitors ..............................33Diuretics, Loop .........................33Diuretics, Potassium-sparing ....33Diuretics, Thiazide....................33divalproex sodium ....................10divalproex sodium dr................10divalproex sodium er ................10divigel.......................................43docetaxel inj 80mg/8ml ............17donepezil hcl.............................11Dopamine Agonists ..................20Dopamine Precursors/ L-Amino AcidDecarboxylase Inhibitors......20doribax inj 500mg.......................7dorzolamide hcl ........................52dorzolamide hcl/timolol maleate52dovonex ....................................37doxazosin mesylate...................29doxepin hcl ...............................13doxil..........................................18doxycycline caps 75mg ..............9doxycycline hyclate caps............9doxycycline hyclate inj...............9doxycycline hyclate tabs 100mg.9doxycycline hyclate tabs 20mg...9doxycycline hyclate tbec 150mg 9doxycycline monohydrate tabs 150mg,50mg.......................................9dronabinol caps 10mg...............13dronabinol caps 2.5mg, 5mg.....14droxia caps 300mg....................17dulera ........................................54durezol ......................................51dynacirc cr tb24 10mg ..............31dynacirc cr tb24 5mg ................31dyrenium...................................33Dyslipidemics, Fibric Acid Derivatives..............................................34Dyslipidemics, HMG CoA ReductaseInhibitors ..............................34Dyslipidemics, Other................34Ee.e.s. 400.....................................8e.e.s. granules .............................8econazole nitrate.......................14edarbi ........................................30edecrin ......................................33edurant ......................................22effient tabs 10mg ......................29effient tabs 5mg ........................29Electrolyte/ Mineral Modifiers .56Electrolyte/ Mineral Replacement56elestat........................................51elestrin ......................................43elidel .........................................37eligard inj 22.5mg, 30mg, 7.5mg47eligard inj 45mg........................47eliphos.......................................40elixophyllin...............................54elmiron......................................40eloxatin inj 100mg/20ml...........18emadine.....................................51emcyt ........................................17emend caps 0 ............................14emend caps 125mg, 40mg ........14emend caps 80mg .....................14Emetogenic Therapy Adjuncts .13emoquette .................................44emsam pt24 12mg/24hr ............12emsam pt24 6mg/24hr, 9mg/24hr12emtriva......................................22enablex......................................40enalapril maleate.................30, 32enalapril maleate/hydrochlorothiazide..............................................32enbrel inj 25mg...................47, 48enbrel inj 25mg/0.5ml...............48enbrel inj 50mg/ml ...................47endocet tabs 325mg, 10mg, 325mg,7.5mg......................................1endocet tabs 325mg, 5mg ...........1endocet tabs 500mg, 7.5mg ........1endocet tabs 650mg, 10mg .........1endodan.......................................163

engerix-b inj 10mcg/0.5ml, 20mcg/ml..............................................49enjuvia tabs 0.3mg, 0.45mg, 0.625mg,0.9mg....................................43enjuvia tabs 1.25mg..................43enoxaparin sodium inj 100mg/ml,120mg/0.8ml, 150mg/ml......28enoxaparin sodium inj 30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml.....28enoxaparin sodium inj 80mg/0.8ml..............................................28enpresse-28 ...............................44enulose......................................39Enzyme Inhibitors.....................18Enzyme Replacement/ Modifiers38epinastine hcl............................51epinephrine hcl inj 0.1mg/ml....54epipen 2-pak .............................54epipen-jr 2-pak..........................54epitol.........................................11epivir hbv..................................24epivir soln .................................22eplerenone.................................33eprosartan mesylate ..................30epzicom.....................................22equetro cp12 100mg, 300mg ....11equetro cp12 200mg .................11erbitux.......................................18ergocalciferol............................58ergoloid mesylates ....................11Ergot Alkaloids.........................15erivedge ....................................18errin...........................................46ertaczo.......................................14ery...............................................8eryped 200 ..................................8eryped 400 ..................................8ery-tab.........................................8erythrocin stearate.......................8erythromycin ethylsuccinate.......8erythromycin gel, oint, soln........8erythromycin/benzoyl peroxide 37escitalopram oxalate soln..........12escitalopram oxalate tabs 10mg12escitalopram oxalate tabs 20mg, 5mg..............................................12estrace.......................................43estradiol ptwk 0.025mg/24hr,0.05mg/24hr, 0.06mg/24hr,0.1mg/24hr, 37.5mcg/24hr...43estradiol ptwk 0.075mg/24hr....43estradiol tabs.............................43estradiol valerate.......................43estradiol/norethindrone acetate.44estring .......................................44Estrogens ..................................43estropipate.................................44ethambutol hcl ..........................16ethosuximide...............................9etidronate disodium tabs 400mg50etodolac caps 200mg ..................2etodolac er ..................................2etodolac tabs ...............................2etoposide inj..............................18eurax .........................................20evamist......................................44evista.........................................46evoxac.......................................36exalgo tb24 12mg, 8mg ..............3exalgo tb24 16mg .......................3exelderm ...................................14exelon pt24 ...............................11exelon soln................................11exemestane ...............................18exforge......................................32exforge hct................................32exjade........................................56extavia.......................................36fabrazyme .................................38factive .........................................8famciclovir................................24famotidine inj, susr ...................39famotidine tabs 20mg, 40mg ....39fanapt tabs 10mg, 12mg, 6mg, 8mg..............................................21fanapt tabs 1mg, 2mg, 4mg ......21fareston .....................................17faslodex.....................................18fazaclo tbdp 100mg, 25mg .......22felbamate ..................................10felodipine er..............................31femhrt low dose ........................44femring .....................................44femtrace tabs 0.45mg................44femtrace tabs 0.9mg..................44fenofibrate micronized..............34fenofibrate tabs 145mg, 48mg ..34fenofibrate tabs 160mg, 54mg ..34fenoglide...................................34fenoprofen calcium.....................2fentanyl citrate oral transmucosal3fentanyl pt72 100mcg/hr.............3fentanyl pt72 12mcg/hr, 25mcg/hr,50mcg/hr, 75mcg/hr ...............3fentora.........................................3Fibromyalgia Agents ................36finacea.......................................37finasteride tabs 5mg..................40Ffirmagon inj 120mg ..................47flarex.........................................51flavoxate hcl .............................40flecainide acetate ......................30flector..........................................2flovent diskus............................53flovent hfa.................................53fluconazole ...............................14fluconazole in dextrose inj 56mg/ml,400mg/200ml .......................14flucytosine ................................14fludrocortisone acetate..............41flunisolide soln 0.025% ............53fluocinolone acetonide crea, oint, soln..............................................41fluocinolone acetonide oil ........41fluocinonide..............................41fluocinonide-e...........................41fluoroplex .................................37fluorouracil crea, inj .................37fluorouracil external soln..........37fluoxetine hcl............................12fluphenazine decanoate.............21fluphenazine hcl........................21flurbiprofen...........................2, 51flurbiprofen sodium..................51flutamide...................................47fluticasone propionate.........41, 53fluvastatin caps 20mg ...............34fluvastatin caps 40mg ...............34fluvoxamine maleate.................12fml.............................................51fml forte....................................51focalin xr cp24 10mg, 15mg.....35focalin xr cp24 20mg................36folic acid ...................................58fondaparinux sodium inj 10mg/0.8ml,5mg/0.4ml, 7.5mg/0.6ml......28fondaparinux sodium inj 2.5mg/0.5ml..............................................28foradil aerolizer ........................54forfivo xl...................................11forteo.........................................50fortical.......................................50fosamax plus d..........................50foscarnet sodium.......................22fosinopril sodium................30, 32fosinopril sodium/hydrochlorothiazide..............................................32fosrenol chew 1000mg, 500mg 40fragmin inj 12500unit/0.5ml,15000unit/0.6ml, 18000unt/0.72ml,7500unit/0.3ml .....................28fragmin inj 2500unit/0.2ml.......28freamine iii 3% .........................5764

frova..........................................16furosemide inj, tabs...................33furosemide oral soln 10mg/ml..33fuzeon inj 90mg........................23GGABA Receptor Modulators ....56gabapentin.................................10gabitril tabs 12mg .....................10gabitril tabs 16mg, 4mg............10gabitril tabs 2mg .......................10galantamine hydrobromide.......11gamastan s/d .............................48Gamma-aminobutyric Acid (GABA)Augmenting Agents................9gammagard liquid.....................48ganciclovir ................................22gardasil .....................................49Gastrointestinal Agents.......38, 39Gastrointestinal Agents, Other .38gavilyte-c ..................................39gavilyte-g..................................39gavilyte-n/flavor pack...............39gelnique gel 10% ......................40gemcitabine hcl inj 1gm ...........17gemfibrozil ...............................34generlac.....................................39gengraf......................................48Genitourinary Agents ...............40Genitourinary Agents, Other ....40genotropin.................................42genotropin miniquick inj 0.2mg42genotropin miniquick inj 0.4mg, 0.8mg,1mg.......................................42gentak oint ..................................5gentamicin sulfate crea, inj, oint,ophthalmic soln ......................5gentamicin sulfate/0.9% sodiumchloride inj 1.6mg/ml, 0.9%,1mg/ml, 0.9%.........................5geodon ......................................21gianvi ........................................44gilenya ......................................36gleevec tabs 100mg ..................19gleevec tabs 400mg ..................19glimepiride tabs 1mg ................26glimepiride tabs 2mg ................26glimepiride tabs 4mg ................26glipizide er tb24 10mg..............26glipizide er tb24 2.5mg.............26glipizide er tb24 5mg................26glipizide tabs 10mg...................26glipizide tabs 5mg.....................26glipizide/metformin hcl tabs 2.5mg,250mg...................................27glipizide/metformin hcl tabs 2.5mg,500mg, 5mg, 500mg.............27glucagen hypokit.......................27glucagon emergency kit............27Glucocorticoids...................41, 49Glucocorticoids/ Mineralocorticoids..............................................41Glutamate Reducing Agents.....10glyburide micronized tabs 1.5mg26glyburide micronized tabs 3mg 26glyburide micronized tabs 6mg 26glyburide tabs 1.25mg ..............26glyburide tabs 2.5mg ................26glyburide tabs 5mg ...................26glyburide/metformin hcl tabs 1.25mg,250mg...................................27glyburide/metformin hcl tabs 2.5mg,500mg, 5mg, 500mg.............27Glycemic Agents ......................27glycopyrrolate inj......................38glycopyrrolate tabs ...................38glyset.........................................26golytely.....................................39granisetron hcl inj 1mg/ml........14granisetron hcl tabs...................14griseofulvin microsize susp ......14griseofulvin microsize tabs.......14griseofulvin ultramicrosize.......15gris-peg .....................................14guanfacine hcl...........................29Hhalflytely bowel prep/flavor packs..............................................39halobetasol propionate..............42halog .........................................42haloperidol................................21haloperidol decanoate...............21haloperidol lactate.....................21havrix........................................49hectorol caps.............................50helidac.......................................39heparin sodium .........................28heparin sodium/nacl 0.45% ......28hepatasol...................................57hepsera......................................24herceptin ...................................18hexalen......................................16Histamine2 (H2) Receptor Antagonists..............................................39Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal)........................................41, 42Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)..............................................42Hormonal Agents, Stimulant/Replacement/ Modifying (SexHormones/ Modifiers)....43, 44Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)..............................................46Hormonal Agents, Suppressant(Adrenal) ..............................46Hormonal Agents, Suppressant(Parathyroid) ........................46Hormonal Agents, Suppressant(Pituitary) .............................46Hormonal Agents, Suppressant (SexHormones/ Modifiers)..........47Hormonal Agents, Suppressant(Thyroid) ..............................47humalog ....................................27humalog kwikpen .....................27humalog mix 50/50...................27humalog mix 50/50 kwikpen ....27humalog mix 75/25...................27humalog mix 75/25 kwikpen ....27humatrope.................................42humira.......................................48humulin 70/30.....................27, 28humulin 70/30 pen....................28humulin n..................................28humulin n u-100 pen.................28humulin r ..................................28humulin r u-500 (concentrated) 28hydralazine hcl tabs ..................35hydrochlorothiazide..................34hydrocodone bitartrate/acetaminophensoln.........................................1hydrocodone bitartrate/acetaminophentabs 300mg, 10mg ..................1hydrocodone bitartrate/acetaminophentabs 300mg, 5mg ....................1hydrocodone bitartrate/acetaminophentabs 750mg, 10mg ..................1hydrocodone bitartrate/homatropinemethylbromide .....................53hydrocodone/acetaminophen soln1hydrocodone/acetaminophen tabs325mg, 10mg, 500mg, 10mg,500mg, 7.5mg, 650mg, 10mg,650mg, 7.5mg, 660mg, 10mg 1hydrocodone/acetaminophen tabs325mg, 5mg............................1hydrocodone/acetaminophen tabs325mg, 7.5mg, 500mg, 2.5mg,500mg, 5mg............................1hydrocodone/acetaminophen tabs750mg, 7.5mg.........................165

hydrocodone/ibuprofen...............1hydrocortisone ....................42, 50hydrocortisone butyrate ............42hydrocortisone lotn, tabs...........42hydrocortisone oint...................42hydrocortisone valerate.............42hydromorphone hcl inj 500mg/50ml................................................4hydromorphone hcl tabs .............4hydroxychloroquine sulfate ......19hydroxyurea..............................17hydroxyzine hcl ........................13hydroxyzine pamoate................13ibandronate sodium...................50ibuprofen susp.............................2ibuprofen tabs 400mg, 600mg, 800mg................................................2iclusig tabs 15mg......................17iclusig tabs 45mg......................17imipenem/cilastatin.....................7imipramine hcl..........................13imipramine pamoate caps 100mg,150mg, 75mg........................13imipramine pamoate caps 125mg13imiquimod.................................37imitrex soln...............................16Immune Suppressants...............47Immunizing Agents, Passive ....48Immunological Agents .............47Immunomodulators...................48imovax rabies (h.d.c.v.) ............49incivek ......................................24increlex .....................................42indapamide ...............................34indocin susp................................2indomethacin caps ......................2indomethacin er ..........................2infanrix .....................................49Inflammatory Bowel Disease Agents..............................................49inlyta.........................................18innopran xl................................31Insulins .....................................27intelence tabs 100mg ................22intelence tabs 200mg ................22intralipid ...................................57intron-a inj 6000000unit/ml......24intron-a w/diluent inj 10mu ......24introvale....................................44intuniv.......................................36invanz .........................................7invega sustenna inj 117mg/0.75ml,156mg/ml, 234mg/1.5ml......21Iinvega sustenna inj 39mg/0.25ml,78mg/0.5ml ..........................21invega tb24 1.5mg, 3mg ...........21invega tb24 6mg .......................21invega tb24 9mg .......................21invirase caps .............................23invirase tabs..............................23ionosol-b/dextrose 5% ..............57ipol inactivated ipv ...................49ipratropium bromide inhalation soln..............................................54ipratropium bromide nasal soln 54ipratropium bromide/albuterol sulfate..............................................55irbesartan ............................30, 32irbesartan/hydrochlorothiazide .32irinotecan inj 100mg/5ml..........18Irritable Bowel Syndrome Agents39isentress chew...........................23isentress tabs.............................23isolyte-p/dextrose 5% ...............57isoniazid tabs ............................16isordil titradose .........................35isosorbide dinitrate ...................35isosorbide dinitrate er ...............35isosorbide mononitrate er .........35isosorbide mononitrate tabs 10mg35isosorbide mononitrate tabs 20mg35isotonic gentamicin inj 0.8mg/ml, 0.9%................................................5isradipine ..................................31istalol ........................................52itraconazole...............................15ixempra kit inj 45mg.................18ixiaro.........................................49jakafi.........................................18jalyn ..........................................40jantoven ....................................28janumet .....................................27janumet xr.................................27januvia ......................................26jevtana.......................................18jinteli.........................................44jolivette.....................................46junel 1.5/30...............................44junel 1/20..................................44junel fe 1.5/30...........................44junel fe 1/20..............................45JKkaletra soln................................23kaletra tabs 100mg, 25mg.........23kaletra tabs 200mg, 50mg.........23kalydeco....................................55kanamycin sulfate.......................5kariva ........................................45kcl 0.075%/d5w/nacl 0.45%.....57kcl 0.15%/d5w/lr ......................57kcl 0.15%/d5w/nacl 0.2%.........57kcl 0.15%/d5w/nacl 0.9%.........57kcl 0.3%/d5w/nacl 0.45%.........57kcl 0.3%/d5w/nacl 0.9%...........57kelnor 1/35................................45kenalog .....................................42ketoconazole crea, sham, tabs...15ketoconazole foam....................15ketoprofen...................................2ketoprofen er...............................2ketorolac tromethamine ........2, 51ketorolac tromethamine inj 15mg/ml,30mg/ml .................................2ketorolac tromethamine tabs.......2kineret.......................................48kionex .......................................56klor-con 10................................56klor-con 8..................................56klor-con m15 ............................56klor-con m20 ............................56kombiglyze xr tb24 1000mg, 2.5mg..............................................27kombiglyze xr tb24 1000mg, 5mg,500mg, 5mg..........................27kristalose...................................39kuvan ........................................38labetalol hcl tabs.......................31laclotion ....................................37lactated ringers irrigation..........58lactated ringers viaflex..............58lactulose....................................39lamictal odt tbdp 100mg, 25mg 10lamictal odt tbdp 200mg...........10lamictal starter/not takingcarbamazepine......................10lamictal starter/takingcarbamazepine/not taking valproate..............................................10lamictal starter/taking valproate10lamictal xr kit 0.........................10lamictal xr tb24 100mg, 25mg, 50mg..............................................10lamictal xr tb24 200mg.............10lamictal xr tb24 250mg.............10lamivudine ................................22lamivudine/zidovudine .............22lamotrigine................................1066L

lamotrigine er tb24 100mg, 25mg,50mg.....................................10lamotrigine er tb24 200mg .......10lamotrigine er tb24 250mg, 300mg..............................................10lanoxin tabs...............................32lansoprazole..............................40lantus.........................................28lantus solostar ...........................28lastacaft.....................................51latanoprost ................................52latuda tabs 120mg, 20mg, 80mg21latuda tabs 40mg.......................21Laxatives...................................39leena..........................................45leflunomide...............................48lescol xl.....................................34lessina .......................................45letairis .......................................55letrozole ....................................18leucovorin calcium inj 100mg, 350mg..............................................17leucovorin calcium tabs............17leukeran ....................................17leukine ......................................29leuprolide acetate......................47levalbuterol 1.25 MG/0.5ML....54levatol .......................................31levemir......................................28levemir flexpen.........................28levetiracetam er...........................9levetiracetam inj 500mg/5ml ......9levetiracetam oral soln, tabs .......9levobunolol hcl soln 0.5% ........52levocarnitine .............................58levocetirizine dihydrochloride tabs..............................................53levofloxacin ................................8levofloxacin in d5w inj 5%,500mg/100ml .........................8levonorgestrel/ethinyl estradiol 45levora 0.15/30-28......................45levothroid..................................46levothyroxine sodium ...............46levoxyl ......................................46lexiva susp ................................23lexiva tabs.................................23lialda .........................................49lidocaine hcl external soln ..........4lidocaine hcl inj 1% ....................4lidocaine hcl jelly........................4lidocaine oint ..............................4lidocaine viscous.........................4lidocaine/prilocaine crea.............4lidoderm......................................4lincocin .......................................6lindane lotn ...............................20lindane sham.............................20linzess .......................................39liothyronine sodium..................46lipofen caps 150mg...................34lisinopril..............................30, 32lisinopril/hydrochlorothiazide ..32lithium carbonate ......................25lithium carbonate er..................25lithium citrate............................25livalo.........................................34Local Anesthetics .......................4locoid lipocream .......................42lodosyn .....................................20lofibra tabs 160mg....................34loperamide hcl caps ..................38lorazepam intensol....................25lorazepam tabs 0.5mg...............25lorazepam tabs 1mg..................25lorazepam tabs 2mg..................25lorzone ......................................55losartan potassium ..............30, 33losartan potassium/hydrochlorothiazide..............................................33lotemax .....................................51lotronex.....................................39lovastatin...................................34lovaza........................................34lovenox .....................................28low-ogestrel ..............................45loxapine succinate.....................21lufyllin ......................................54lumigan soln 0.01% ..................52lumigan soln 0.03% ..................52lunesta.......................................56lupron depot inj 22.5mg, 3.75mg,30mg, 45mg, 7.5mg..............47lupron depot-ped inj 11.25mg, 15mg..............................................47lutera.........................................45lyrica caps 100mg, 150mg, 200mg,25mg, 50mg, 75mg.................9lyrica caps 225mg, 300mg..........9lyrica soln ...................................9lysodren ....................................46Mmacrodantin caps 25mg..............6Macrolides ..................................8malathion ..................................20maprotiline hcl..........................11marlissa.....................................45marplan.....................................12Mast Cell Stabilizers.................55matulane ...................................17matzim la ..................................31maxair autohaler .......................54maxalt .......................................16maxalt-mlt.................................16maxidex ....................................51meclizine hcl.............................13meclofenamate sodium caps 100mg................................................2meclofenamate sodium caps 50mg................................................2medroxyprogesterone acetate inj46medroxyprogesterone acetate tabs46mefenamic acid...........................2mefloquine hcl..........................19megestrol acetate ......................46meloxicam susp ..........................3meloxicam tabs...........................2menactra ...................................49menest.......................................44menomune-a/c/y/w-135............49menostar ...................................44mentax ......................................15menveo .....................................49meperidine hcl inj 100mg/ml, 25mg/ml,50mg/ml .................................4meperitab ....................................4meprobamate ............................25mepron......................................19mercaptopurine.........................48meropenem inj 500mg................7mesalamine kit..........................49mesna........................................18mesnex tabs ..............................18mestinon syrp............................16mestinon timespan....................16Metabolic Bone Disease Agents50metadate cd cpcr 10mg, 20mg..36metadate cd cpcr 60mg.............36metadate er................................36metaproterenol sulfate syrp ......54metformin hcl er tb24 500mg ...26metformin hcl er tb24 750mg ...26metformin hcl tabs 1000mg......26metformin hcl tabs 500mg........26metformin hcl tabs 850mg........26methadone hcl soln 5mg/5ml......3methadone hcl tabs .....................3methamphetamine hcl...............35methazolamide..........................33methenamine hippurate...............6methimazole .............................47methitest ...................................43methocarbamol .........................55methotrexate .............................4867

methotrexate sodium inj 25mg/ml48methscopolamine bromide........38methyclothiazide.......................34methyldopa .........................29, 33methyldopa/hydrochlorothiazide33methylphenidate hcl..................36methylphenidate hcl cd cpcr 10mg..............................................36methylphenidate hcl cd cpcr 50mg,60mg.....................................36methylphenidate hcl er tbcr 20mg36methylphenidate hydrochloride 36methylprednisolone ..................42methylprednisolone acetate ......42methylprednisolone dose pack..42methylprednisolone sodiumsuccinateinj 125mg, 40mg ..................42methylprednisolone sodiumsuccinateinj 1gm .................................42metipranolol..............................52metoclopramide hcl ..................13metolazone................................34metoprolol succinate er.............31metoprolol tartrate tabs.............31metoprolol/hydrochlorothiazide33metrogel......................................6metronidazole caps .....................6metronidazole crea, gel, lotn, tabs6metronidazole in nacl 0.79% ......6metronidazole vaginal.................6mexiletine hcl ...........................30micardis ..............................30, 33micardis hct ..............................33miconazole 3.............................15microgestin 1.5/30 ....................45microgestin 1/20 .......................45microgestin fe ...........................45microgestin fe 1.5/30 ................45midodrine hcl............................29migergot....................................15migranal....................................16millipred .............................42, 51minitran.....................................35minocycline hcl.....................9, 36minocycline hcl caps ..................9minoxidil...................................35mirtazapine .........................11, 12mirtazapine odt tbdp 30mg, 45mg12misoprostol tabs 200mcg..........39mitomycin inj 20mg..................18mitoxantrone hcl.......................17m-m-r ii w/diluent 10 dose .......49modafinil...................................56moexipril hcl.............................30moexipril/hydrochlorothiazide .33Molecular Target Inhibitors......18mometasone furoate..................42Monoamine Oxidase B (MAO-B)Inhibitors ..............................20Monoamine Oxidase Inhibitors 12Monoclonal Antibodies ............19mononessa ................................45montelukast sodium chew, tabs 53monurol.......................................6Mood Stabilizers.......................25morphine sulfate er cp24 ............3morphine sulfate er tb12.............3morphine sulfate soln, tabs .........3moviprep...................................39moxeza........................................8ms contin tb12 100mg, 15mg, 30mg,60mg.......................................3multaq.......................................30Multiple Sclerosis Agents.........36mupirocin oint.............................6mustargen .................................18mycamine .................................15mycobutin.................................16mycophenolate mofetil .............48myfortic tbec 180mg.................48myfortic tbec 360mg.................48myozyme ..................................38nabumetone.................................3nadolol ................................31, 33nadolol/bendroflumethiazide ....33nafcillin sodium inj 1gm.............7naftin crea 1%...........................15naftin gel...................................15naglazyme.................................38nalbuphine hcl.............................4nalfon........................................34naloxone hcl................................4naltrexone hcl .............................4namenda soln............................11namenda tabs ............................11namenda titration pak ...............11naproxen .................................3, 5naproxen dr.................................3naproxen sodium tabs 275mg, 550mg................................................3naratriptan hcl...........................16nasonex.....................................53natacyn......................................15nateglinide ................................26nebupent ...................................19necon 0.5/35-28 ........................45necon 1/35 ................................45necon 7/7/7 ...............................45Nnefazodone hcl..........................12neomycin sulfate.........................5neomycin/bacitracin/polymyxin50neomycin/polymyxin/bacitracin/hydrocortisone.................................50neomycin/polymyxin/dexamethasone..............................................50neomycin/polymyxin/gramicidin51neomycin/polymyxin/hc ...........52neomycin/polymyxin/hydrocortisone........................................51, 52neomycin/polymyxin/hydrocortisoneotic susp................................52nephramine ...............................58neulasta.....................................29neumega....................................29neupogen...................................29nevanac.....................................51nevirapine tabs..........................22nexavar .....................................19nexium cpdr..............................40nexium i.v.................................40nexium pack 10mg, 20mg, 40mg40next choice................................46niacor ........................................34niaspan......................................34nicardipine hcl caps ..................31nicotrol ns ...................................5nifediac cc tb24 90mg...............31nifedical xl................................32nifedipine..................................32nifedipine er..............................32nilandron...................................47nimodipine................................32nisoldipine ................................32nisoldipine er ............................32nitro-bid ....................................35nitrofurantoin..............................6nitrofurantoin macrocrystalline caps50mg.......................................6nitrofurantoin monohydrate........6nitroglycerin .............................35nitroglycerin transdermal..........35nitrolingual pumpspray.............35nitromist....................................35nitrostat.....................................35nizatidine ..................................39N-methyl-D-aspartate (NMDA)Receptor Antagonist.............11Nonsteroidal Anti-inflammatory Drugs............................................2, 5nora-be......................................46norditropin flexpro....................42norditropin nordiflex pen..........43norethindrone acetate................4668

normosol-m in d5w...................58normosol-r in d5w ....................58norpace cr cp12 100mg.............30nortrel 0.5/35 (28).....................45nortrel 1/35 ...............................45nortrel 7/7/7 ..............................45nortriptyline hcl caps ................13norvir ........................................23novarel ......................................43novolin 70/30............................28novolin n...................................28novolin r....................................28novolog.....................................28novolog flexpen ........................28novolog mix 70/30....................28novolog mix 70/30 prefilled flexpen..............................................28noxafil.......................................15nucynta ...................................3, 4nucynta er tb12 100mg, 150mg, 200mg,250mg.....................................3nucynta er tb12 50mg .................3nuedexta....................................36nutropin aq pen .........................43nuvigil.......................................56nystatin crea, oint, susp, tabs ....15nystatin/triamcinolone ..............37nystop .......................................15Oocella.........................................45octreotide acetate inj 1000mcg/ml,200mcg/ml, 500mcg/ml .......47octreotide acetate inj 100mcg/ml,50mcg/ml..............................47ofloxacin ophthalmic soln, otic soln................................................8ofloxacin tabs..............................8olanzapine...........................12, 21olanzapine odt...........................21olanzapine/fluoxetine caps 25mg,12mg, 50mg, 12mg, 50mg, 6mg..............................................12olanzapine/fluoxetine caps 25mg, 3mg..............................................12olanzapine/fluoxetine caps 25mg, 6mg..............................................12omeprazole cpdr .......................40omnitrope..................................43ondansetron hcl soln .................14ondansetron hcl tabs 24mg .......14ondansetron hcl tabs 4mg, 8mg 14ondansetron odt tbdp 4mg ........14ondansetron odt tbdp 8mg ........14onfi..............................................9onglyza tabs 2.5mg...................26onglyza tabs 5mg......................26onmel ........................................15onsolis film 200mcg ...................3onsolis film 400mcg ...................3opana er (crush resistant) tb12 10mg,20mg, 30mg, 5mg...................3opana er (crush resistant) tb12 40mg................................................3Ophthalmic Agents...................50Ophthalmic Agents, Other........50Ophthalmic Anti-allergy Agents51Ophthalmic Antiglaucoma Agents52Ophthalmic Anti-inflammatories51Ophthalmic Prostaglandin andProstamide Analogs..............52Opioid Analgesics, Long-acting .3Opioid Analgesics, Short-acting.4Opioid Antagonists.....................4orap...........................................21orapred odt..........................42, 51orencia ......................................48orfadin.......................................38orphenadrine citrate ............55, 56orphenadrine citrate er..............56orphenadrine/asa/caffeine...........1orsythia .....................................45osmoprep ..................................56Otic Agents...............................52oxandrolone tabs 10mg.............43oxandrolone tabs 2.5mg............43oxaprozin ....................................3oxcarbazepine tabs....................11oxistat .......................................15oxsoralen ultra ..........................37oxybutynin chloride..................40oxybutynin chloride er..............40oxycodone hcl caps.....................4oxycodone hcl conc ....................4oxycodone hcl soln .....................4oxycodone hcl tabs 10mg, 20mg 4oxycodone hcl tabs 15mg, 30mg, 5mg................................................4oxycodone/acetaminophen caps .1oxycodone/acetaminophen tabs 325mg,10mg, 325mg, 2.5mg, 325mg, 7.5mg................................................2oxycodone/acetaminophen tabs 325mg,5mg.........................................1oxycodone/acetaminophen tabs 500mg,7.5mg......................................1oxycodone/acetaminophen tabs 650mg,10mg.......................................1oxycodone/aspirin.......................2oxycodone/ibuprofen..................3oxycontin tb12 10mg, 15mg, 20mg,30mg, 40mg, 60mg ................3oxycontin tb12 80mg..................3oxymorphone hydrochloride...3, 4oxymorphone hydrochloride er tb1215mg.......................................3oxytrol.......................................40Ppacerone tabs 100mg ................30pacerone tabs 200mg ................30paclitaxel inj 300mg/50ml........18pamidronate disodium inj 6mg/ml50pancreaze ..................................38pandel .......................................42panretin.....................................19pantoprazole sodium tbec .........40Parasympathomimetics.............16paromomycin sulfate ..................5paroxetine hcl ...........................12paroxetine hcl er .......................12pataday......................................51patanase ....................................53patanol ......................................51paxil ..........................................12Pediculicides/ Scabicides..........20pedi-dri .....................................15pedvax hib ................................49peganone...................................11pegasys inj 180mcg/0.5ml ........24pegasys inj 180mcg/ml .............24pegasys proclick inj 135mcg/0.5ml..............................................24peg-intron inj 50mcg/0.5ml ......24peg-intron redipen ....................24penicillin g potassium in iso-osmoticdextrose inj 0, 60000unit/ml...7penicillin g potassium inj 5mu....7penicillin g sodium .....................7penicillin v potassium.................8pennsaid......................................3pentasa ......................................49pentazocine/acetaminophen........2pentazocine/naloxone hcl ...........2pentoxifylline er........................32perforomist ...............................54perindopril erbumine ................30periogard...................................36perjeta .......................................18permethrin.................................20perphenazine.......................12, 13perphenazine/amitriptyline .......12pertzye ......................................38pexeva.......................................13phenadoz...................................1369

phenelzine sulfate .....................12phenobarbital elix .......................9phenobarbital tabs 100mg, 15mg, 60mg................................................9phenobarbital tabs 16.2mg, 30mg,64.8mg, 97.2mg......................9phenobarbital tabs 32.4mg..........9phenytek ...................................11phenytoin chew.........................11phenytoin sodium extended......11phenytoin susp..........................11phisohex....................................37phoslyra ....................................41Phosphate Binders ....................40phospholine iodide....................52pilocarpine hcl ..........................37pilocarpine hydrochloride.........37pilopine hs ................................52pindolol.....................................31pioglitazone hcl...................26, 27pioglitazone hcl/metformin hcl.27pioglitazone hcl-glimepiride.....27piperacillin sodium/tazobactam sodiuminj 3gm, 0.375gm ...................8piroxicam....................................3plasma-lyte-148 ........................56plasma-lyte-56/d5w ..................58Platelet Modifying Agents........29podofilox...................................37polyethylene glycol 3350 powd39portia-28 ...................................45potassium chloride..............56, 58potassium chloride 0.15% /nacl 0.45%viaflex...................................56potassium chloride 0.15% d5w/nacl0.33% ...................................58potassium chloride 0.15% d5w/nacl0.45% viaflex ......................58potassium chloride 0.15% nacl 0.9%..............................................56potassium chloride 0.22% d5w/nacl0.45% ...................................58potassium chloride 0.224%/dextrose5% viaflex ............................58potassium chloride 0.3%/d5w...58potassium chloride er................56potassium citrate.......................40potiga ..........................................9pradaxa .....................................28pramipexole dihydrochloride....20prandimet..................................27prandin tabs 0.5mg, 1mg ..........26prandin tabs 2mg ......................26pravastatin sodium....................34prazosin hcl...............................30pred mild...................................52pred-g........................................51prednicarbate ............................42prednisolone acetate .................52prednisolone sodium phosphate42, 52prednisone.................................42prednisone intensol...................42prefest .......................................45pregnyl w/diluent benzyl alcohol/nacl..............................................43premarin crea ............................44premarin tabs 0.3mg, 0.45mg, 0.625mg,0.9mg....................................44premarin tabs 1.25mg ...............44premasol ...................................58premphase.................................45prempro.....................................45prevalite powd ..........................34previfem....................................45prevpac .....................................39prezista tabs 150mg, 400mg, 600mg,800mg...................................23prezista tabs 75mg ....................23primidone..................................10pristiq........................................13proair hfa ..................................54probenecid ................................15probenecid/colchicine...............15procalamine ..............................58prochlorperazine edisylate........13prochlorperazine maleate..........13procrit inj 10000unit/ml, 2000unit/ml,3000unit/ml, 4000unit/ml.....29procrit inj 20000unit/ml, 40000unit/ml..............................................29proctocream hc .........................50procto-pak.................................42proctozone-hc ...........................42progesterone..............................46Progestins .................................46proglycem.................................27prolastin-c .................................55proleukin...................................18prolia.........................................50promacta ...................................29promethazine hcl.......................13promethazine vc..................53, 55promethazine vc/codeine ..........53promethazine/codeine...............53promethazine/dextromethorphan54promethegan supp 25mg, 50mg13propafenone hcl ........................30propafenone hcl er ....................30Prophylactic..............................16propranolol hcl er......................31propranolol hcl tabs ..................31propranolol/hydrochlorothiazide33propylthiouracil ........................47proquad.....................................49prosol ........................................58Protectants ................................39Proton Pump Inhibitors.............39protopic oint 0.03% ..................37protopic oint 0.1% ....................37protriptyline hcl ........................13proventil hfa..............................54Psychotherapeutic Agents.........36pulmicort flexhaler ...................53Pulmonary Antihypertensives...55pulmozyme ...............................55pylera ........................................39pyridostigmine bromide............16Qqualaquin ..................................19quasense....................................45quetiapine fumarate ..................21quinapril hcl..............................30quinapril/hydrochlorothiazide ..33quinidine gluconate er ..............30quinidine sulfate .......................30quinidine sulfate er ...................30quinine sulfate ..........................19Quinolones..................................8qvar...........................................53Rrabavert.....................................49ramipril .....................................30ranexa .......................................32ranitidine hcl caps, syrp, tabs....39rapaflo.......................................40rapamune soln...........................48rapamune tabs 0.5mg................48rapamune tabs 1mg, 2mg..........48rebif...........................................36rebif titration pack ....................36reclast........................................50reclipsen....................................45recombivax hb inj 10mcg/ml,40mcg/ml..............................49rectiv.........................................35regranex ....................................37relenza diskhaler.......................23relistor inj 12mg/0.6ml .............38relpax ........................................16remicade ...................................48renvela pack 0.8gm...................41renvela pack 2.4gm...................4170

envela tabs...............................41reprexain.....................................2rescriptor tabs 100mg ...............22rescriptor tabs 200mg ...............22reserpine ...................................33Respiratory Tract Agents....53, 55Respiratory Tract Agents, Other55restasis ......................................50Retinoids...................................19retrovir iv infusion....................22revatio tabs................................55revlimid caps 10mg, 5mg .........17revlimid caps 15mg, 25mg .......17reyataz caps 100mg ..................23reyataz caps 150mg, 200mg, 300mg..............................................23rheumatrex................................48rhinocort aqua...........................53ribapak tabs 400mg...................24ribasphere caps .........................24ribasphere tabs 200mg..............24ribasphere tabs 400mg, 600mg.24ribavirin ....................................24ridaura.......................................48rifampin ....................................16rifater ........................................16rilutek........................................36rimantadine hcl .........................23risperdal consta inj 12.5mg, 25mg21risperdal consta inj 37.5mg.......21risperdal consta inj 50mg..........21risperidone ................................21risperidone odt ..........................21rituxan.......................................19rivastigmine tartrate..................11rizatriptan benzoate...................16ropinirole er ..............................20ropinirole hcl.............................20rotateq.......................................49roxicet.........................................2rozerem.....................................56Ssabril pack.................................10sabril tabs..................................10saizen click.easy .......................43samsca.......................................56sanctura xr ................................40sancuso .....................................14sandostatin lar depot .................47santyl.........................................37saphris.......................................21savella.......................................36savella titration pack.................36Selective Estrogen Receptor ModifyingAgents ..................................46selegiline hcl.............................20selenium sulfide lotn.................37selzentry tabs 150mg ................23selzentry tabs 300mg ................23sensipar.....................................46serevent diskus..........................54seroquel xr tb24 150mg, 200mg12seroquel xr tb24 300mg, 400mg, 50mg..............................................12Serotonin (5-HT) 1b/1d ReceptorAgonists................................16Serotonin/ Norepinephrine ReuptakeInhibitors ..............................12sertraline hcl .............................13sildenafil citrate ........................55silenor .......................................13silver sulfadiazine.......................8simcor .................................33, 34simcor tb24 1000mg, 40mg, 500mg,40mg.....................................34simponi .....................................48simvastatin tabs 10mg, 20mg, 40mg,5mg.......................................34simvastatin tabs 80mg ..............34singulair ....................................53Skeletal Muscle Relaxants........55sklice.........................................20Sleep Disorder Agents..............56Sleep Disorders, Other..............56Smoking Cessation Agents.........5Sodium Channel Agents ...........10sodium chloride ........................56sodium chloride 0.45% viaflex.56sodium chloride 0.9%...............56sodium sulfacetamide .................9solaraze.....................................37solu-cortef inj 100mg................42solu-cortef inj 250mg................42soma tabs 250mg ......................56somatuline depot inj 120mg/0.5ml,60mg/0.2ml ..........................47somavert ...................................47soriatane....................................37sorine ........................................30sotalol hcl (af) tabs 120mg .......30sotalol hcl tabs 160mg, 240mg, 80mg..............................................30spectracef tabs 400mg ................7spiriva handihaler .....................54spironolactone...........................33spironolactone/hydrochlorothiazide..............................................33sporanox soln............................15sprintec 28 ................................45sprycel tabs 100mg, 50mg, 70mg19sprycel tabs 140mg, 80mg........19sprycel tabs 20mg .....................19sronyx .......................................45ssd...............................................9SSRIs/ SNRIs ...........................25stagesic .......................................2stalevo 100................................20stalevo 125................................20stalevo 150................................20stalevo 200................................20stalevo 50..................................20stalevo 75..................................20stavudine caps...........................23stavudine solr............................23stavzor cpdr 500mg ..................10stelara........................................38sterile water irrigation...............58stivarga .....................................18strattera .....................................36striant ........................................43stribild.......................................23stromectol .................................19suboxone.................................4, 5suboxone film 12mg, 3mg..........5suboxone film 4mg, 1mg............5sucralfate...................................39sulfacetamide sodium ...........9, 51sulfacetamide sodium susp .........9sulfacetamide sodium/prednisolonesodium phosphate.................51sulfadiazine.................................9sulfamethoxazole/trimethoprim..9sulfamethoxazole/trimethoprim ds................................................9sulfamylon crea ..........................6sulfasalazine tabs......................50sulfazine ec ...............................50Sulfonamides ........................8, 50sulindac.......................................3sumatriptan succinate inj 6mg/0.5ml..............................................16sumatriptan succinate tabs........16suprax chew, tabs........................7suprax susr 100mg/5ml...............7suprep bowel prep.....................56sustiva.......................................22sutent caps 12.5mg ...................19sutent caps 25mg, 50mg ...........19sylatron .....................................24symbicort ..................................55symbyax caps 25mg, 12mg, 50mg,12mg.....................................12symbyax caps 25mg, 3mg ........12symbyax caps 25mg, 6mg ........1271

symbyax caps 50mg, 6mg ........12symlinpen 120...........................26symlinpen 60 ............................26synalgos-dc .................................2synarel.......................................47synercid.......................................6synribo ......................................17synthroid...................................46tabloid.......................................17taclonex.....................................38tacrolimus caps 0.5mg ..............48tacrolimus caps 1mg .................48tacrolimus caps 5mg .................48tamiflu caps 45mg, 75mg .........23tamoxifen citrate.......................17tamsulosin hcl...........................40tarceva tabs 100mg, 150mg ......19tarceva tabs 25mg .....................19targretin.....................................19tarka ..........................................33tasigna.......................................19tasmar .......................................20taxotere inj 80mg/4ml...............18tazorac.......................................38taztia xt .....................................32teflaro inj 400mg ........................7tegretol......................................11tegretol-xr .................................11tekamlo .....................................33tekturna...............................32, 33tekturna hct ...............................33temazepam................................25terazosin hcl..............................30terbinafine hcl tabs....................15terbutaline sulfate .....................54terconazole crea 0.4%...............15terconazole crea 0.8%...............15terconazole supp .......................15testosterone cypionate...............43testosterone enanthate...............43testred .......................................43tetanus toxoid adsorbed ............49tetanus/diphtheria toxoids-adsorbedadult......................................49tetracycline hcl............................9Tetracyclines...............................9tev-tropin ..................................43thalitone ....................................34thalomid caps 100mg, 50mg.....17thalomid caps 150mg, 200mg...17theophylline cr ..........................54theophylline er tb12 300mg, 450mg..............................................54Ttheophylline er tb24..................54Therapeutic Nutrients/ Minerals/Electrolytes...........................56thermazene..................................9thioridazine hcl .........................21thiothixene ................................21tiagabine hydrochloride ............10ticlopidine hcl ...........................29tikosyn ......................................31timolol maleate ...................16, 52timolol maleate ophthalmic gel forming..............................................52tinidazole ..................................20tirosint.......................................46tizanidine hcl.......................22, 56tobi..............................................5tobradex oint...............................5tobradex st ................................51tobramycin sulfate inj 10mg/ml,80mg/2ml ...............................5tobramycin sulfate ophthalmic soln................................................5tobramycin/dexamethasone ......51tobrex oint...................................5tolazamide tabs 500mg .............26tolbutamide...............................26tolmetin sodium..........................3tolterodine tartrate.....................40topiramate.................................10torsemide tabs...........................33toviaz ........................................40tracleer tabs 125mg...................55tracleer tabs 62.5mg..................55tradjenta ....................................27tramadol hcl............................3, 4tramadol hcl er tb24....................3tramadol hydrochloride/acetaminophen................................................2trandolapril ...............................30tranexamic acid.........................29transderm-scop..........................13tranylcypromine sulfate ............12travasol .....................................58travatan z ..................................52trazodone hcl tabs 100mg, 150mg,50mg.....................................12trazodone hcl tabs 300mg .........12treanda ......................................18Treatment-Resistant..................22trelstar depot mixject ................47trelstar la mixject ......................47tretinoin caps.............................19tretinoin crea, gel ......................19trexall tabs 10mg, 15mg ...........48triamcinolone acetonide......42, 53triamcinolone in orabase...........37triamterene/hydrochlorothiazide33tribenzor....................................33Tricyclics ..................................13trifluoperazine hcl.....................21trifluridine.................................24trihexyphenidyl hcl tabs............20tri-legest fe................................45trileptal susp..............................11trilipix .......................................34trilyte.........................................39trimethobenzamide hcl caps .....13trimethoprim.........................6, 51trimethoprim sulfate/polymyxin bsulfate ...................................51trimipramine maleate................13trinessa......................................45tri-previfem...............................45tri-sprintec.................................45trivora-28 ..................................45trizivir .......................................23trospium chloride......................40trospium chloride er..................40truvada ......................................23tudorza pressair.........................54twinject inj 0.3mg/0.3ml...........54twinrix.......................................49twynsta......................................33tygacil .........................................6tykerb........................................19typhim vi...................................49tysabri .......................................36tyzeka........................................24tyzine ........................................55tyzine pediatric nasal drops ......55Uu-cort.........................................42uloric.........................................15ultresa .......................................38unithroid ...................................46ursodiol caps.............................39ursodiol tabs..............................39Vaccines ...................................48vagifem.....................................44valacyclovir hcl ........................24valcyte tabs ...............................22valproate sodium ......................10valproic acid .............................10valsartan/hydrochlorothiazide ..33vancomycin hcl caps...................6vancomycin hcl inj 1000mg, 10gm,V72

500mg.....................................6vandazole....................................6vaqta inj 25unit/0.5ml...............49varivax ......................................49vascepa .....................................34Vasodilating Agents .................35Vasodilators, Direct-acting Arterial........................................34, 35Vasodilators, Direct-acting Arterial/Venous..................................34vectibix .....................................18vectical......................................38velcade......................................18velivet .......................................45venlafaxine hcl....................13, 25venlafaxine hcl er................13, 25ventavis soln 10mcg/ml ............55ventolin hfa...............................54veramyst ...................................53verapamil hcl er ........................32verapamil hcl tabs.....................32veregen .....................................38vesicare.....................................40vestura.......................................45vexol .........................................52vfend iv.....................................15viagra ........................................35victoza.......................................27victrelis .....................................24vidaza........................................18videx pediatric solr 2gm ...........23vigamox ......................................8viibryd kit .................................12viibryd tabs ...............................12vimpat inj..................................11vimpat oral soln ........................11vimpat tabs................................11vincasar pfs...............................18viokace......................................38viracept .....................................23viramune susp...........................22viramune xr...............................22virazole .....................................24viread powd ..............................23viread tabs.................................23Vitamin B Complex..................58Vitamin D .................................58Vitamins ...................................58vivelle-dot pttw 0.025mg/24hr,0.0375mg/24hr .....................44vivelle-dot pttw 0.05mg/24hr,0.1mg/24hr ...........................44voltaren.....................................38voriconazole inj ........................15voriconazole tabs 200mg..........15voriconazole tabs 50mg............15votrient......................................19vytorin tabs 10mg, 10mg, 10mg, 20mg,10mg, 40mg..........................33vytorin tabs 10mg, 80mg..........33Wwarfarin sodium........................28welchol .....................................27Xxalkori.......................................19xarelto tabs 10mg......................28xarelto tabs 15mg, 20mg ..........28xeljanz.......................................48xenazine....................................36xeomin ......................................22xgeva.........................................50xifaxan tabs 200mg.....................6xifaxan tabs 550mg.....................6xolair.........................................55xopenex hfa ..............................55xtandi ........................................18xyrem........................................56Yyervoy.......................................17yf-vax........................................49zafirlukast .................................53Zzaleplon.....................................56zaltrap inj 100mg/4ml...............17zavesca......................................38zazole crea ................................15zelapar.......................................20zelboraf.....................................17zemaira .....................................55zemplar caps 1mcg, 2mcg ........50zemplar inj 2mcg/ml.................50zenchent fe................................46zenpep.......................................38zeosa .........................................46zerit solr....................................23zetia...........................................34ziagen........................................23zidovudine ................................23ziprasidone hcl..........................21zirgan ........................................22zithromax pack ...........................8zolinza.......................................15zolpidem tartrate.......................56zolpidem tartrate er...................56zometa inj 4mg/5ml..................50zomig soln ................................16zomig tabs.................................16zomig zmt .................................16zonalon .....................................38zonisamide..................................9zortress tabs 0.5mg, 0.75mg .....48zostavax ....................................49zovia 1/35e................................46zovia 1/50e................................46zovirax crea ..............................24zovirax oint...............................24zyclara.......................................38zyflo cr......................................53zylet ..........................................51zymaxid ......................................8zytiga ........................................47zyvox inj .....................................6zyvox susr...................................6zyvox tabs...................................673