Prescription Drug Guide Comprehensive list of covered drugs

category name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 53. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand name drugs and generic drugs are listed in the Index. Look in the Index andfind your drug. Next to your drug, you will see the page number where you can find coverageinformation. Turn to the page listed in the Index and find the name of your drug in the first columnof the list.What are generic drugs?Simply Healthcare Plans, Inc. covers both brand name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand name drug. Generally, genericdrugs cost less than brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:Prior Authorization: Simply Healthcare Plans, Inc. requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from SimplyHealthcare Plans, Inc. before you fill your prescriptions. If you don’t get approval, SimplyHealthcare Plans, Inc. may not cover the drug.Quantity Limits: For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drugthat Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to astandard one month or three month supply.Step Therapy: In some cases, Simply Healthcare Plans, Inc. requires you to first try certaindrugs to treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc.may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SimplyHealthcare Plans, Inc. will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. You can also get more information about the restrictions applied to specific covereddrugs by visiting our Web site at www.mysimplymedicare.com.You can ask Simply Healthcare Plans, Inc. to make an exception to these restrictions or limits. See thesection, “How do I request an exception to the Simply Healthcare Plans, Inc.’s formulary?” on page ivfor information about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary, you should first contact Member Services and confirm thatyour drug is not covered. If you learn that Simply Healthcare Plans, Inc. does not cover your drug, youiii