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/LimitsPHOSLYRA 4RENVELA TABS 4RENVELA PACK 2.4GM 5 QL (180 EA per 30 days)RENVELA PACK 0.8GM 5 QL (525 EA per 30 days)Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)Glucocorticoids/ Mineralocorticoidsa-hydrocort 2 MO GCalclometasone dipropionate 1 MO GCamcinonide 1 MO GCaugmented betamethasone dipropionate 1 MO GCbetamethasone dipropionate 1 MO GCbetamethasone valerate foam 1 MO GCbetamethasone valerate crea, lotn, oint 1 MO GCCAPEX 4CELESTONE 4clobetasol propionate e 1 MO GCclobetasol propionate gel, oint, soln 1 MO GCclobetasol propionate foam, lotn, sham 2 MO GCCORDRAN 4CORDRAN TAPE 4cortisone acetate 1 MO GCDERMA-SMOOTHE/FS BODY OIL 3 MODESONATE 4desonide crea 1 MO GCdesonide lotn, oint 2 MO GCDESOWEN 4desoximetasone crea, gel 2 MO GCdesoximetasone oint 0.05% 2 MO GCdesoximetasone oint 0.25% 2 MO GCdexamethasone 1 MO GCdexamethasone intensol 1 MO GCdexamethasone sodium phosphate 1 MO GCdiflorasone diacetate 2 MO GCfludrocortisone acetate 1 MO GCfluocinolone acetonide crea, oint, soln 1 MO GCfluocinolone acetonide oil 2 MO GCfluocinonide 1 MO GCfluocinonide-e 1 MO GCfluticasone propionate 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 41 <strong>of</strong> 73
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