Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsTRADJENTA 3 QL (30 EA per 30 days) MOVICTOZA 4 QL (18 ML per 28 days)WELCHOL 3 MOBlood Glucose RegulatorsACTOPLUS MET 4 GC DACTOPLUS MET XR 4 GC DAVANDAMET 4 GC DAVANDARYL 4 GC Dglipizide/metformin hcl tabs 2.5mg, 500mg, 5mg, 500mg 1 QL (120 EA per 30 days) MO GCglipizide/metformin hcl tabs 2.5mg, 250mg 1 QL (240 EA per 30 days) MO GCglyburide/metformin hcl tabs 2.5mg, 500mg, 5mg, 500mg 1 QL (120 EA per 30 days) MO GCglyburide/metformin hcl tabs 1.25mg, 250mg 1 QL (240 EA per 30 days) MO GCJANUMET 3 QL (60 EA per 30 days) MOJANUMET XR 3 QL (30 EA per 30 days) MOKOMBIGLYZE XR TB24 1000MG, 5MG, 500MG, 5MG 4 QL (30 EA per 30 days)KOMBIGLYZE XR TB24 1000MG, 2.5MG 4 QL (60 EA per 30 days)pioglitazone hcl-glimepiride 2 MO GCpioglitazone hcl/metformin hcl 2 MO GCPRANDIMET 4 QL (150 EA per 30 days)Glycemic AgentsGLUCAGEN HYPOKIT 4GLUCAGON EMERGENCY KIT 3 MOPROGLYCEM 4InsulinsAPIDRA 4 GC DAPIDRA SOLOSTAR 4 GC Dbd insulin syringe safetyglide/1ml/29g x 1/2" 2 MO GCbd insulin syringe ultrafine/0.3ml/31g x 5/16" 2 MO GCbd insulin syringe ultrafine/0.5ml/30g x 1/2" 2 MO GCbd insulin syringe ultrafine/1ml/31g x 5/16" 2 MO GCbd pen needle/ultrafine/29g x 12.7mm 2 MO GCcurity gauze pads 2"x2" 2 MO GCHUMALOG 3 MO GC DHUMALOG KWIKPEN 3 MO GC DHUMALOG MIX 50/50 3 MO GC DHUMALOG MIX 50/50 KWIKPEN 3 MO GC DHUMALOG MIX 75/25 3 MO GC DHUMALOG MIX 75/25 KWIKPEN 3 MO GC DHUMULIN 70/30 3 MO GC DPA = 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 27 of 73