Prescription Drug Guide Comprehensive list of covered drugs

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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
Page 2 and 3: Simply Healthcare Plans, Inc.2013 F
Page 4 and 5: category name for your drug.Alphabe
Page 6 and 7: course of action for you, we may co
Page 8 and 9: FormularyDrug TierFormulary DrugLab
Page 10 and 11: ¿Qué es el Formulario de Simply H
Page 12 and 13: Usted puede consultar el formulario
Page 14 and 15: Si desea más informaciónSi desea
Page 16: Nivel delMedicamentoen elFormulario
Page 19: Drug NameDrugTier Requirements/Limi
Page 23 and 24: Drug NameDrugTier Requirements/Limi
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Drug NameDrugTier Requirements/Limi
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ampicillin-sulbactam inj 10gm, 5gm,
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celebrex caps 100mg ...............
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engerix-b inj 10mcg/0.5ml, 20mcg/ml
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hydrocodone/ibuprofen..............
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methotrexate sodium inj 25mg/ml48me
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phenelzine sulfate ................
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symbyax caps 50mg, 6mg ........12sy
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Prescription Drug Guide Comprehensive list of covered drugs

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