Prescription Drug Guide Comprehensive list of covered drugs
Prescription Drug Guide Comprehensive list of covered drugs
Prescription Drug Guide Comprehensive list of covered drugs
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<strong>Drug</strong> Name<strong>Drug</strong>Tier 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 <strong>of</strong> 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 <strong>of</strong>Coverage for more information. ED = Excluded <strong>Drug</strong>: This prescription drug is not normally <strong>covered</strong> in a Medicare<strong>Prescription</strong> <strong>Drug</strong> 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 <strong>of</strong> 73
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