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/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 <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 23 <strong>of</strong> 73
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