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/LimitsNORDITROPIN NORDIFLEX PEN 5 PAnovarel 2 PA MONUTROPIN AQ PEN 5 ST PAOMNITROPE 4 PApregnyl w/diluent benzyl alcohol/nacl 2 PA MO GCSAIZEN CLICK.EASY 5 ST PATEV-TROPIN 5 ST PAHormonal Agents, Stimulant/ Replacement/ Modifying (SexHormones/ Modifiers)Anabolic SteroidsOXANDROLONE TABS 10MG 5 PAoxandrolone tabs 2.5mg 2 PA MO GCAndrogensANDRODERM 3 PA MOANDROGEL 3 PA MOANDROGEL PUMP 3 PA MOANDROXY 4danazol 2 MO GCMETHITEST 3 MOSTRIANT 4 QL (60 EA per 30 days) ST PAtestosterone cypionate 1 PA MO GCtestosterone enanthate 1 PA MO GCTESTRED 4 PAEstrogensALORA PTTW 0.05MG/24HR, 0.075MG/24HR,4 QL (8 EA per 28 days)0.1MG/24HRALORA PTTW 0.025MG/24HR 4 QL (8 EA per 30 days)CENESTIN 4 PADEPO-ESTRADIOL 4DIVIGEL 4ELESTRIN 4ENJUVIA TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG 4 QL (30 EA per 30 days)ENJUVIA TABS 1.25MG 4 QL (60 EA per 30 days)ESTRACE 4estradiol valerate 2 MO GCestradiol tabs 1 MO GCestradiol ptwk 0.025mg/24hr, 0.05mg/24hr, 0.06mg/24hr, 1 MO GC0.1mg/24hr, 37.5mcg/24hrestradiol ptwk 0.075mg/24hr 2 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 43 <strong>of</strong> 73
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