Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsanagrelide hydrochloride 2 MO GCARANESP ALBUMIN FREE INJ 60MCG/ML 4 QL (2.4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 40MCG/ML 4 QL (3.2 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 25MCG/ML 4 QL (4 ML per 30 days) ST PAARANESP ALBUMIN FREE INJ 500MCG/ML 5 QL (1 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 200MCG/ML 5 QL (1.6 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 300MCG/0.6ML 5 QL (2.4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 100MCG/ML 5 QL (4 ML per 28 days) ST PALEUKINE 5 PANEULASTA 5 PANEUPOGEN 5 PAPROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,4 QL (12 ML per 30 days) PA3000UNIT/ML, 4000UNIT/MLPROCRIT INJ 20000UNIT/ML, 40000UNIT/ML 5 QL (12 ML per 30 days) PAPROMACTA 5 QL (30 EA per 30 days) PABlood Products/ Modifiers/ Volume ExpandersCINRYZE 5 PANEUMEGA 5 PACoagulantstranexamic acid 2 MO GCPlatelet Modifying AgentsAGGRENOX 4 QL (60 EA per 30 days)cilostazol 1 MO GCclopidogrel tabs 300mg 2 MO GCclopidogrel tabs 75mg 2 QL (34 EA per 30 days) MO GCdipyridamole 1 PA MO GCEFFIENT TABS 10MG 4 QL (36 EA per 30 days)EFFIENT TABS 5MG 4 QL (43 EA per 30 days)ticlopidine hcl 1 MO GCCardiovascular AgentsAlpha-adrenergic Agonistsclonidine hcl tabs 1 MO GCclonidine hcl ptwk 2 MO GCguanfacine hcl 1 MO GCmethyldopa 2 MO GCmidodrine hcl 2 MO GCAlpha-adrenergic Blocking AgentsDIBENZYLINE 4doxazosin mesylate 1 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 29 of 73