Prescription Drug Guide Comprehensive list of covered drugs

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