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/Limitsursodiol caps 1 MO GCursodiol tabs 2 MO GCGastrointestinal AgentsCOLYTE-FLAVOR PACKS 4gavilyte-c 1 MO GCgavilyte-g 1 MO GCgavilyte-n/flavor pack 1 MO GCGOLYTELY 4HELIDAC 4 QL (56 EA per 30 days)PREVPAC 4 QL (14 EA per 30 days)PYLERA 4 QL (120 EA per 30 days)trilyte 1 MO GCHistamine2 (H2) Receptor Antagonistscimetidine 1 MO GCcimetidine hcl soln 1 MO GCfamotidine inj, susr 1 MO GCfamotidine tabs 20mg, 40mg 1 MO GCnizatidine 1 MO GCranitidine hcl caps, syrp, tabs 1 MO GCIrritable Bowel Syndrome AgentsAMITIZA 4 QL (60 EA per 30 days) STbudesonide 2 MO GCLINZESS 4 QL (30 EA per 30 days) PALOTRONEX 3 QL (60 EA per 30 days) PA MOLaxativesconstulose 1 MO GCenulose 1 MO GCgenerlac 1 MO GCHALFLYTELY BOWEL PREP/FLAVOR PACKS 4KRISTALOSE 4lactulose 1 MO GCMOVIPREP 4polyethylene glycol 3350 powd 1 MO GCProtectantsCARAFATE SUSP 4misoprostol tabs 200mcg 1 MO GCsucralfate 1 MO GCProton Pump InhibitorsDEXILANT 4 QL (30 EA per 30 days) STPA = 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 39 <strong>of</strong> 73
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