Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsCOMVAX 4DAPTACEL 4DECAVAC 3 MOENGERIX-B INJ 10MCG/0.5ML, 20MCG/ML 3 B/D MOGARDASIL 4HAVRIX 3 MOIMOVAX RABIES (H.D.C.V.) 4INFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4M-M-R II W/DILUENT 10 DOSE 4MENACTRA 4MENOMUNE-A/C/Y/W-135 4MENVEO 4PEDVAX HIB 4PROQUAD 4RABAVERT 4RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML 4 B/DROTATEQ 4TETANUS TOXOID ADSORBED 3 MOTETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 3 MOTWINRIX 4TYPHIM VI 4VAQTA INJ 25UNIT/0.5ML 4VARIVAX 4YF-VAX 4ZOSTAVAX 4 QL (1 EA per 365 days)Inflammatory Bowel Disease AgentsAminosalicylatesAPRISO 3 MOASACOL 4ASACOL HD 4balsalazide disodium 2 MO GCCANASA 4DIPENTUM 4LIALDA 4mesalamine kit 2 MO GCPENTASA 4GlucocorticoidsPA = 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 of 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 ofCoverage for more information. ED = Excluded Drug: This prescription drug is not normally covered in a MedicarePrescription Drug 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 49 of 73