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/LimitsDILATRATE SR 4ISORDIL TITRADOSE 4isosorbide dinitrate 1 MO GCisosorbide dinitrate er 1 MO GCisosorbide mononitrate er 1 MO GCisosorbide mononitrate tabs 10mg 1 MO GCisosorbide mononitrate tabs 20mg 1 MO GCminitran 1 MO GCNITRO-BID 3 MOnitroglycerin 1 MO GCnitroglycerin transdermal 1 MO GCnitrolingual pumpspray 2 MO GCNITROMIST 4NITROSTAT 3 MORECTIV 3 MOVasodilators, Direct-acting Arterialhydralazine hcl tabs 1 MO GCminoxidil 1 MO GCCardiovascular <strong>Drug</strong>sVasodilating AgentsCIALIS 1 QL (6 EA per 31 days) MO GC EDVIAGRA 1 QL (6 EA per 31 days) MO GC EDCentral Nervous System AgentsAttention Deficit Hyperactivity Disorder Agents, AmphetaminesADDERALL XR CP24 2.5MG, 2.5MG, 2.5MG, 2.5MG, 4 QL (30 EA per 30 days) PA3.75MG, 3.75MG, 3.75MG, 3.75MG, 5MG, 5MG, 5MG,5MG, 6.25MG, 6.25MG, 6.25MG, 6.25MG, 7.5MG, 7.5MG,7.5MG, 7.5MGadderall xr cp24 1.25mg, 1.25mg, 1.25mg, 1.25mg 2 QL (30 EA per 30 days) PA MO GCamphetamine/dextroamphetamine tabs 1 PA MO GCamphetamine/dextroamphetamine cp24 2 QL (30 EA per 30 days) PA MOdextroamphetamine sulfate 1 PA MO GCdextroamphetamine sulfate er 2 PA MO GCmethamphetamine hcl 2 PA MO GCAttention Deficit Hyperactivity Disorder Agents, NonamphetaminesDAYTRANA 4 QL (30 EA per 30 days) PAdexmethylphenidate hcl 1 MO GCFOCALIN XR CP24 10MG, 15MG 4 QL (30 EA per 30 days) PAPA = 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 35 <strong>of</strong> 73
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