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/Limitsneomycin/polymyxin/gramicidin 1 MO GCneomycin/polymyxin/hydrocortisone 2 MO GCPRED-G 3 MOsulfacetamide sodium 1 MO GCsulfacetamide sodium/prednisolone sodium phosphate 1 MO GCTOBRADEX ST 4tobramycin/dexamethasone 2 MO GCtrimethoprim sulfate/polymyxin b sulfate 1 MO GCZYLET 4Ophthalmic Anti-allergy AgentsALOCRIL 4ALOMIDE 4azelastine hcl 2 MO GCBEPREVE 4cromolyn sodium 1 MO GCELESTAT 4 STEMADINE 4epinastine hcl 2 MO GCLASTACAFT 4PATADAY 4PATANOL 4Ophthalmic Anti-inflammatoriesACUVAIL 4ALREX 4BROMDAY 3 MObromfenac 2 MO GCdexamethasone sodium phosphate 1 MO GCdicl<strong>of</strong>enac sodium 1 MO GCDUREZOL 4FLAREX 3 MOflurbipr<strong>of</strong>en sodium 1 MO GCFML 3 MOFML FORTE 3 MOketorolac tromethamine 1 MO GCLOTEMAX 4MAXIDEX 3 MOMILLIPRED 4NEVANAC 4ORAPRED ODT 4PA = 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 51 <strong>of</strong> 73
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