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/Limitslosartan potassium/hydrochlorothiazide 1 MO GCmethyldopa/hydrochlorothiazide 2 MO GCmetoprolol/hydrochlorothiazide 1 MO GCMICARDIS HCT 4 QL (30 EA per 30 days) STmoexipril/hydrochlorothiazide 2 MO GCnadolol/bendr<strong>of</strong>lumethiazide 2 MO GCpropranolol/hydrochlorothiazide 1 MO GCquinapril/hydrochlorothiazide 1 MO GCreserpine 2 MO GCSIMCOR 4 QL (30 EA per 30 days)spironolactone/hydrochlorothiazide 1 MO GCTARKA 4TEKAMLO 4 QL (30 EA per 30 days) STTEKTURNA HCT 4 QL (30 EA per 30 days) STtriamterene/hydrochlorothiazide 1 MO GCTRIBENZOR 3 QL (30 EA per 30 days) ST MOTWYNSTA 3 QL (30 EA per 30 days) ST MOvalsartan/hydrochlorothiazide 2 MOVYTORIN TABS 10MG, 10MG, 10MG, 20MG, 10MG, 4 QL (30 EA per 30 days) ST40MGVYTORIN TABS 10MG, 80MG 4 QL (30 EA per 30 days) ST PADiuretics, Carbonic Anhydrase Inhibitorsacetazolamide 1 MO GCacetazolamide er 2 MO GCmethazolamide 1 MO GCDiuretics, Loopbumetanide 1 MO GCEDECRIN 4furosemide inj, tabs 1 MO GCfurosemide oral soln 10mg/ml 1 MO GCtorsemide tabs 1 MO GCDiuretics, Potassium-sparingamiloride hcl 1 MO GCDYRENIUM 4eplerenone 2 MO GCspironolactone 1 MO GCDiuretics, Thiazidechlorothiazide 1 MO GCchlorthalidone tabs 25mg, 50mg 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 <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 33 <strong>of</strong> 73
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