Prescription Drug Guide Comprehensive list of covered drugs

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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
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 and 20: Drug NameDrugTier Requirements/Limi
Page 35: Drug NameDrugTier Requirements/Limi
Page 76 and 77: ampicillin-sulbactam inj 10gm, 5gm,
Page 78 and 79: celebrex caps 100mg ...............
Page 80 and 81: engerix-b inj 10mcg/0.5ml, 20mcg/ml
Page 82 and 83: hydrocodone/ibuprofen..............
Page 84 and 85: methotrexate sodium inj 25mg/ml48me
Page 86 and 87:
phenelzine sulfate ................
Page 88 and 89:
symbyax caps 50mg, 6mg ........12sy
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Prescription Drug Guide Comprehensive list of covered drugs

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