Prescription Drug Guide Comprehensive list of covered drugs

Prescription Drug GuideGuía de Medicamentos RecetadosComprehensive list ofcovered drugsLista de medicamentos cubiertos2013South Florida & Tampa RegionSur de la Florida y Región de TampaPLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLAN.FAVOR LEER: ESTE DOCUMENTO CONTIENE INFORMACIONSOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN.H5471_SHP 2013CFORM_BIL

Simply Healthcare Plans, Inc.2013 Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WECOVER IN THIS PLANNote to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,2014.Simply HealthCare Plans, Inc. is a Coordinated Care plan with a Medicare contract and a contract withthe Florida Medicaid program.This information is available for free in other languages. Please contact our Member Services number at1-877-577-0115 for additional information. If you use a TTY device, please call 711. We are open 7days a week, 8 a.m. to 8 p.m. From February 15 th until September 30 th , you may leave us a voice mailmessage after hours, Saturdays, Sundays and holidays, and we will return your call the next businessday.Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestronúmero de atención al afiliado al 1-877-577-0115 para obtener información adicional. Si usted usa undispositivo TTY, por favor llame al 711. El horario de atención es de 8 a.m. a 8 p.m., los siete días de lasemana. A partir del 15 de febrero hasta el 30 de septiembre usted puede dejarnos un mensaje en elcorreo de voz después del horario de trabajo, los sábados, domingos y días festivos y nosotros ledevolveremos la llamada el siguiente día hábil.Formulary ID: 13569 Ver. 10H5471_SHP 2013CForm_BILi

What is the Simply Healthcare Plans, Inc.’s Formulary?A formulary is a list of covered drugs selected by Simply Healthcare Plans, Inc. in consultation with ateam of health care providers, which represents the prescription therapies believed to be a necessary partof a quality treatment program. Simply Healthcare Plans, Inc. will generally cover the drugs listed inour formulary as long as the drug is medically necessary, the prescription is filled at a Simply HealthcarePlans, Inc. network pharmacy, and other plan rules are followed. For more information on how to fillyour prescriptions, please review your Evidence of Coverage.Can the Formulary change?Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when anew, less expensive generic drug becomes available or when new adverse information about the safetyor effectiveness of a drug is released. Other types of formulary changes, such as removing a drug fromour formulary, will not affect members who are currently taking the drug. It will remain available at thesame cost-sharing for those members taking it for the remainder of the coverage year. We feel it isimportant that you have continued access for the remainder of the coverage year to the formulary drugsthat were available when you chose our plan, except for cases in which you can save additional moneyor we can ensure your safety.If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapyrestrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members ofthe change at least 60 days before the change becomes effective, or at the time the member requests arefill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food andDrug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removesthe drug from the market, we will immediately remove the drug from our formulary and provide noticeto members who take the drug. The enclosed formulary is current as of September 1, 2012. To getupdated information about the drugs covered by Simply Healthcare Plans, Inc., please visit our Web siteat www.mysimplymedicare.com or call Member Services at 1-877-577-0115. We are open 7 days aweek, 8 a.m to 8 p.m. From February 15 until the following Annual Election Period (AEP), you mayleave us a voice mail message after-hours, Saturdays, Sundays and holidays and we will return your callthe next business day. TTY/TDD users should call 711. In the event of a mid-year non-maintenanceformulary change such as changing a preferred or non-preferred formulary drug, adding an additionalrequirement or limit to a drug, remove a dosage form, or exchanging therapeutic alternatives by addingor deleting a drug or changing a tier as a result of a therapeutic alternative, we will notify you byproviding you with a written notice of the non-maintenance formulary change.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories dependingon the type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, “Cardiovascular Agents”. If you know what your drug isused for, look for the category name in the list that begins on page number 1. Then look under theii

category name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 53. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand name drugs and generic drugs are listed in the Index. Look in the Index andfind your drug. Next to your drug, you will see the page number where you can find coverageinformation. Turn to the page listed in the Index and find the name of your drug in the first columnof the list.What are generic drugs?Simply Healthcare Plans, Inc. covers both brand name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand name drug. Generally, genericdrugs cost less than brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:Prior Authorization: Simply Healthcare Plans, Inc. requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from SimplyHealthcare Plans, Inc. before you fill your prescriptions. If you don’t get approval, SimplyHealthcare Plans, Inc. may not cover the drug.Quantity Limits: For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drugthat Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to astandard one month or three month supply.Step Therapy: In some cases, Simply Healthcare Plans, Inc. requires you to first try certaindrugs to treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc.may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SimplyHealthcare Plans, Inc. will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. You can also get more information about the restrictions applied to specific covereddrugs by visiting our Web site at www.mysimplymedicare.com.You can ask Simply Healthcare Plans, Inc. to make an exception to these restrictions or limits. See thesection, “How do I request an exception to the Simply Healthcare Plans, Inc.’s formulary?” on page ivfor information about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary, you should first contact Member Services and confirm thatyour drug is not covered. If you learn that Simply Healthcare Plans, Inc. does not cover your drug, youiii

have two options:You can ask Member Services for a list of similar drugs that are covered by Simply HealthcarePlans, Inc. When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Simply Healthcare Plans, Inc.You can ask Simply Healthcare Plans, Inc. to make an exception and cover your drug. See belowfor information about how to request an exception.How do I request an exception to the Simply Healthcare Plans, Inc.’s Formulary?You can ask Simply Healthcare Plans, Inc. to make an exception to our coverage rules. There areseveral types of exceptions that you can ask us to make.You can ask us to cover your drug even if it is not on our formulary.You can ask us to waive coverage restrictions or limits on your drug. For example, for certaindrugs, Simply Healthcare Plans, Inc. limits the amount of the drug that we will cover. If yourdrug has a quantity limit, you can ask us to waive the limit and cover more.You can ask us to provide a higher level of coverage for your drug. If your drug is contained inour non-preferred brand tier, you can ask us to cover it at the cost-sharing amount that applies todrugs in the preferred brand tier instead. This would lower the amount you must pay for yourdrug. Please note, if we grant your request to cover a drug that is not on our formulary, you maynot ask us to provide a higher level of coverage for the drug. “Also, you may not ask us toprovide a higher level of coverage for drugs that are in the Tier 5, Specialty tier.”Generally, Simply Healthcare Plans, Inc. will only approve your request for an exception if thealternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilizationrestrictions would not be as effective in treating your condition and/or would cause you to have adversemedical effects.You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilizationrestriction exception. When you are requesting a formulary, tiering or utilization restrictionexception you should submit a statement from your physician supporting your request. Generally,we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’ssupporting statement. You can request an expedited (fast) exception if you or your doctor believe thatyour health could be seriously harmed by waiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s orprescribing physician’s supporting statement.What do I do before I can talk to my doctor about changing my drugs or requestingan exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,you may be taking a drug that is on our formulary but your ability to get it is limited. For example, youmay need a prior authorization from us before you can fill your prescription. You should talk to yourdoctor to decide if you should switch to an appropriate drug that we cover or request a formularyexception so that we will cover the drug you take. While you talk to your doctor to determine the rightiv

course of action for you, we may cover your drug in certain cases during the first 90 days you are amember of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we willcover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go toa network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you havebeen a member of the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill your prescription until wehave provided you with a 93-day transition supply, consistent with the dispensing increment, (unlessyou have a prescription written for fewer days). We will cover more than one refill of these drugs for thefirst 90 days you are a member of our plan. If you need a drug that is not on our formulary or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while youpursue a formulary exception.For current members who are changing from one treatment setting to another, for example entering along- term care facility from a hospital or being discharged from a hospital to home, the member andprovider will need to utilize our exception and appeals process should the drugs not be on our formulary.Members entering or being discharged from a long-term care facility will be allowed a one-timeemergency supply of a 31-day supply for medications which the member has not already received atransition supply. In addition, the dispensing pharmacist will need to call the Pharmacy Help Desk toreceive appropriate directions to dispense a prescription required due to a level of care change.For more informationFor more detailed information about your Simply Healthcare Plans, Inc. prescription drug coverage,please review your Evidence of Coverage and other plan materials.If you have questions about Simply Healthcare Plans, Inc., please call Member Services at 1-877-577-0115. If you use a TTY device, please call 711. We are open 7 days a week, 8 a.m. to 8 p.m. FromFebruary 15 th until September 30 th , you may leave us a voice mail message after hours, Saturdays,Sundays and holidays, and we will return your call the next business day. Or visitwww.mysimplymedicare.com.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.Simply Healthcare Plans, Inc.’s FormularyThe formulary below provides coverage information about some of the drugs covered by SimplyHealthcarePlans, Inc. If you have trouble finding your drug in the list, turn to the Index that begins on page 53.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR 10MG) and generic drugs are listed in lower-case italics (e.g., pravastatin sodium 10 mg).v

The information in the Requirements/Limits column tells you if Simply Healthcare Plans, Inc. has anyspecial requirements for coverage of your drug.List of AbbreviationsB/DEDGCGC DLAMOPAQLSTThis prescription drug has a Part B versus D administrative prior authorization requirement. Thisdrug may be covered under Medicare Part B or D depending upon the circumstances.Information may need to be submitted describing the use and setting of the drug to make thedetermination.This prescription drug is not normally covered in a Medicare Prescription Drug Plan. Theamount 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). Inaddition, if you are receiving extra help to pay for your prescriptions, you will not get any extrahelp to pay for this drug.Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.Please refer to our Evidence of Coverage for more information about this coverage.Additional Gap Coverage for specific plans. We provide additional coverage of this prescriptiondrug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage.Limited Availability. This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.Mail Order Drug. This prescription drug is available through a mail-order service.Prior Authorization. Simply Healthcare Plans, Inc. requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from SimplyHealthcare Plans, Inc. before you fill your prescriptions. If you don't get approval, SimplyHealthcare Plans, Inc. may not cover the drug.Quantity Limit. For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drugthat Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.provides 30 tablets per prescription for Celebrex 100mg Capsules. This may be in addition to astandard one month or three month supply.Step Therapy. In some cases, Simply Healthcare Plans, Inc requires you to first try certain drugsto treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Incmay not cover drug B unless you try Drug A first. If Drug A does not work for you, SimplyHealthcare Plans, Inc will then cover Drug.vi

FormularyDrug TierFormulary DrugLabel NameCopayment/Co-insuranceat Retail and Mail OrderPharmacies1 Preferred Generic Lowest Copayment2 Non-Preferred Generic Low Copayment3 Preferred Brand Medium Copayment4 Non-Preferred Brand High CopaymentExplanationCopayment for a 30-daysupply retail or 90-daysupply mail-order/ perprescription or refill.Copayment for a 30-daysupply retail or 90-daysupply mail-order/ perprescription or refill.Copayment for a 30-daysupply retail or 90-daysupply mail-order/ perprescription or refill.Copayment for a 30-daysupply retail/ perprescription or refill.5 Specialty Tier High Co-InsuranceCoinsurance for a 30-daysupply retail/ perprescription or refill.Note: Please see your Evidence of Coverage for specific cost sharing amounts and for theavailability of 90-Day Retail & Mail-Order supplies for Tier 1-3. Members getting Extra Help willpay their Low Income Subsidy (LIS) copayment. Please refer to your LIS rider or call MemberServices at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. If you use a TTY device,please call 711.vii

Simply Healthcare Plans, Inc.Formulario de 2013(Lista de medicamentos cubiertos)LEA POR FAVOR: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOSMEDICAMENTOS QUE CUBRE ESTE PLANNota a los afiliados existentes: Este formulario ha cambiado desde el año pasado. Revise estedocumento para asegurarse de que sigue incluyendo los medicamentos que toma.Los beneficiarios deben usar las farmacias de la red para tener acceso a su beneficio de medicamentosrecetados. El 1 de enero de 2014 podría haber cambios en los beneficios, el formulario, la red defarmacias, las primas, los copagos o el coaseguro.Simply HealthCare Plans, Inc. es un Plan de cuidados coordinados con un contrato Medicare Advantagey un contrato con el programa de Medicaid de la Florida.This information is available for free in other languages. Please contact our member service number at1-877-577-0115 for additional information. If you use a TTY device, please call 711. We are open 7days a week, 8 a.m. to 8 p.m. From February 15 th until September 30 th , you may leave us a voice mailmessage after hours, Saturdays, Sundays and holidays, and we will return your call the next businessday.Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestronúmero de atención al afiliado al 1-877-577-0115 para obtener información adicional. Si usted usa undispositivo TTY, por favor llame al 711. El horario de atención es de 8 a.m. a 8 p.m., los siete días de lasemana. A partir del 15 de febrero hasta el 30 de septiembre usted puede dejarnos un mensaje en elcorreo de voz después del horario de trabajo, los sábados, domingos y días festivos y nosotros ledevolveremos la llamada el siguiente día hábil.viii

¿Qué es el Formulario de Simply Healthcare Plans, Inc.?El formulario es una lista de medicamentos seleccionados cubiertos por Simply Healthcare Plans, Inc. encolaboración con un equipo de proveedores de atención médica, que representa las terapiasfarmacológicas consideradas como parte necesaria de un programa de tratamiento de calidad. Por logeneral, Simply Healthcare Plans, Inc. cubrirá los medicamentos incluidos en nuestro formulariosiempre y cuando se necesiten por razones médicas, el medicamento sea surtido en una farmacia de lared de Simply Healthcare Plans, Inc., y se hayan seguido otras reglas de cobertura. Si desea másinformación sobre cómo hacer para que le surtan sus medicamentos recetados, consulte su Evidencia deCobertura.¿Es posible que cambie el formulario?Por lo general, si está tomando un medicamento de nuestro formulario del 2013 que estaba cubierto alprincipio del año, no lo descontinuaremos ni reduciremos su cobertura durante el año de cobertura 2013,excepto cuando un medicamento genérico nuevo y menos costoso se ponga a disposición, o cuando sepublique nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos decambios en el formulario, como el retiro de un medicamento de nuestro formulario, no afectará a losafiliados que están tomando actualmente el medicamento. Seguirá estando disponible con la mismaparticipación de costos para aquellos afiliados que lo están tomando durante el resto del año decobertura. Creemos que es importante que usted tenga acceso continuo durante el resto del año de lacobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan,excepto en los casos en los que pueda ahorrar dinero o podamos garantizar su seguridad.Si retiramos medicamentos de nuestro formulario o añadimos autorizaciones previas, límites en lascantidades o restricciones en la terapia por fases en un medicamento, o trasladamos un medicamento aun nivel con distribución de costos más alta, debemos notificar a los afiliados afectados sobre el cambiocuando menos con 60 días de anticipación a que entre en vigencia. Alternativamente, daremosnotificación cuando el afiliado solicite la repetición de la receta del medicamento, momento en el cual elafiliado recibirá un surtido de 60 días del medicamento en cuestión. Si la Administración de Alimentosy Medicamentos considera que un medicamento en nuestro formulario no es seguro, o el fabricante delmedicamento lo retira del mercado, nosotros eliminaremos inmediatamente dicho medicamento denuestro formulario y daremos aviso a los afiliados que lo usan. El formulario adjunto fue actualizado el1 de Septiembre del 2012. Si desea información actualizada de los medicamentos cubiertos por SimplyHealthcare Plans, Inc., visite nuestro sitio web en www.mysimplymedicare.com o comuníquese con elDepartamento de Servicios para Afiliados llamando al 1-877-577-0115. Estamos disponibles los 7 díasde la semana de 8 a.m. a 8 p.m. a partir del 15 de Febrero hasta el próximo periodo Anual de Elecciones(AEP por sus siglas en Ingles) puede dejarnos un mensaje de voz después del horario de trabajo, lossábados, domingos y días festivos y le devolveremos la llamada al siguiente día hábil. Los usuarios conTTY/TDD deben marcar 711. En caso de que se haga un cambio en el formulario de un medicamentoque no sea de mantenimiento a mitad de año, como el cambio de un medicamento preferido o nopreferido del formulario, añadir un requisito adicional o poner un límite a un medicamento, retirar unaforma de dosis, o intercambiar alternativas terapéuticas agregando o eliminando un medicamento ocambiando un nivel como resultado de una alternativa terapéutica, se lo notificaremos mediante avisopor escrito del cambio en el formulario del medicamento que no es de mantenimiento.ix

¿Cómo uso el formulario?Hay dos maneras de encontrar su medicamento en el formulario.AfecciónEl formulario comienza en la página 1. Los medicamentos en este formulario se agrupan encategorías en función del tipo de afecciones que tratan habitualmente. Por ejemplo, losmedicamentos para tratar afecciones cardiacas se incluyen en la categoría “AgentesCardiovasculares”. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en lalista que comienza en la página 1. A continuación busque su medicamento en dicha categoría.Lista en orden alfabéticoSi no sabe a qué categoría corresponde su medicamento, deberá buscarlo en el Índice que comienzaen la página 53. El Índice ofrece una lista alfabética de todos los medicamentos incluidos en estedocumento. El Índice incluye tanto los medicamentos de marca como los genéricos. Busque en elÍndice para encontrar su medicamento. Junto al medicamento, verá el número de la página quecontiene la información sobre la cobertura. Vaya a la página indicada en el Índice y encuentre elnombre de su medicamento en la primera columna de la lista.¿Qué son los medicamentos genéricos?Simply Healthcare Plans, Inc. cubre medicamentos genéricos y de marca. Un medicamento genéricorecibirá la aprobación de la FDA si tiene el mismo ingrediente activo que el medicamento de marca. Porlo general, los medicamentos genéricos cuestan menos que los de marca.¿Hay restricciones en mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura.Estos requisitos y límites pueden incluir:Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtenganautorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobaciónde Simply Healthcare Plans, Inc. antes de que pueda surtir sus recetas. Si no obtiene laaprobación, es posible que Simply Healthcare Plans, Inc. no cubra el medicamento.Límites en la Cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. limita lacantidad del medicamento que Simply Healthcare Plans, Inc. va a cubrir. Por ejemplo, SimplyHealthcare Plans, Inc. proporciona 30 tabletas por receta del medicamento LIPITOR ENTABLETAS DE 10 MG. Esto puede ser adicional al suministro estándar de un mes o tresmeses.Terapia por Fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebeprimero ciertos medicamentos para tratar su condición médica antes de que demos cobertura aotro medicamento para dicha afección. Por ejemplo, si tanto el Medicamento A como elMedicamento B tratan su condición médica, es posible que Simply Healthcare Plans, Inc. nocubra el Medicamento B a menos que usted pruebe primero el Medicamento A. Si elMedicamento A no funciona en su caso, Simply Healthcare Plans, Inc. cubrirá el MedicamentoB.x

Usted puede consultar el formulario que comienza en la página 1 para determinar si su medicamentotiene requisitos o límites adicionales. También puede obtener más información sobre las restriccionesque se aplican a medicamentos cubiertos específicos si visita nuestro sitio web enwww.mysimplymedicare.com.Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o límites.Consulte la sección “¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?”en la pagina xi obtener información sobre cómo solicitar una excepción.¿Qué sucede si su medicamento no está en el formulario?Si su medicamento no está incluido en esta lista, debe comunicarse primero con el Departamento deServicios para Afiliados para confirmar que no está cubierto. Si se entera de que Simply HealthcarePlans, Inc. no cubre su medicamento, usted tiene dos opciones:Puede comunicarse con el Departamento de Servicios para Afiliados para solicitar una lista delos medicamentos similares que cubre Simply Healthcare Plans, Inc. Cuando la reciba,muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto porSimply Healthcare Plans, Inc.Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones olímites. Consulte la sección que sigue para obtener información sobre cómo solicitar unaexcepción.¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a nuestras reglas de cobertura.Hay varios tipos de excepciones que puede pedir.Puede solicitarnos que cubramos su medicamento aunque no esté incluido en nuestroformulario.Puede solicitarnos que cancelemos las restricciones o limitaciones en la cobertura para sumedicamento. Por ejemplo, en algunos medicamentos, Simply Healthcare Plans, Inc. limita lacantidad que tendrá cobertura. Si su medicamento tiene un límite en la cantidad, puedesolicitarnos que cancelemos dicha limitación y cubramos una mayor cantidad.Puede pedirnos que proporcionemos un nivel de cobertura más alto para su medicamento. Si sumedicamento está incluido en nuestro nivel de medicamentos de marca no preferidos, puedesolicitarnos que en su lugar lo cubramos en el nivel de participación de costos que se aplica a losmedicamentos que están en el nivel de medicamentos de marca preferidos. Esto reduciría lacantidad que debe pagar por el medicamento. Tenga presente que si concedemos la solicitud decubrir un medicamento que no se incluye en nuestro formulario, usted no puede pedirnos quedemos un nivel de cobertura más alto para dicho medicamento. “Asimismo, no puede pedirnosque demos un nivel de cobertura más alto a los medicamentos que están en el Nivel 5, quecorresponde a los medicamentos especiales.”Por lo general, Simply Healthcare Plans, Inc. solo aprobará su solicitud para una excepción si losmedicamentos alternativos incluidos en el formulario del plan, o el medicamento de nivel más bajo o lasxi

estricciones de uso adicional no son tan eficaces para tratar su afección o pueden ocasionar efectosmédicos adversos.Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción en elformulario, el nivel o la limitación en el uso. Cuando solicite una excepción en el formulario, el nivelo la limitación en el uso, debe presentar una declaración de su médico que respalde su solicitud.Por lo general, debemos tomar una decisión en un plazo de 72 horas a partir del momento en el quehayamos recibido la declaración de respaldo de su médico tratante o de quien le receta. Usted puedesolicitar una excepción acelerada (rápida) si su médico considera que una espera de 72 horas para unadecisión puede perjudicar gravemente su salud. Si se concede acelerar su solicitud, debemos otorgarleuna decisión antes de 24 horas a partir del momento en que recibamos la declaración de respaldo de sumédico tratante o de quien le receta.¿Qué debo hacer antes de hablar con mi médico sobre el cambio de mismedicamentos o la solicitud de una excepción?Si usted es afiliado nuevo o continúa en nuestro plan, podría estar tomando medicamentos que no estánen nuestro formulario. O podría estar tomando un medicamento que está en nuestro formulario pero sucapacidad para adquirirlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestraparte para poder surtir su receta. Debe hablar con su médico para decidir si debe cambiar a unmedicamento apropiado que nosotros cubramos o solicitar una excepción en el formulario para quepodamos cubrir el medicamento que está tomando. Mientras habla con su médico para determinar elmejor modo de actuar para usted, podríamos cubrir su medicamento en ciertos casos durante losprimeros 90 días de su afiliación a nuestro plan.Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para adquirirsus medicamentos es limitada, daremos cobertura a un suministro temporal de 30 días (a menos quetenga una receta para un número menor de días) cuando vaya a una farmacia de la red. Después de suprimer suministro de 30 días, nosotros no pagaremos estos medicamentos, incluso si usted ha estadoafiliado al plan menos de 90 días.Si reside en un establecimiento de atención médica prolongada, le permitiremos que surta su receta hastaque hayamos proporcionado un suministro de transición de 93 días, consistente con el incremento en elsuministro, (a menos que su receta indique un número menor de días). Daremos cobertura a más de unsurtido de estos medicamentos durante los primeros 90 días de su afiliación a nuestro plan. Si necesitaun medicamento que no está en nuestro formulario, o si su capacidad para adquirir sus medicamentos eslimitada, pero han pasado los primeros 90 días de su afiliación a nuestro plan, daremos cobertura a unsuministro de emergencia de 31 días de dicho medicamento (a menos que su receta indique un númeromenor de días) mientras busca una excepción en el formulario.Para los afiliados actuales que están cambiando de un lugar de tratamiento a otro, por ejemplo, sidespués de estar en un hospital ingresan a un establecimiento de atención médica prolongada, o queregresan a su hogar después de ser dados de alta de un hospital, el afiliado y el proveedor deberánutilizar nuestro proceso de excepciones y apelaciones en caso de que los medicamentos no estén ennuestro formulario. Los afiliados que ingresan a un establecimiento de atención médica prolongada, oque salen de él, tendrán permitido un suministro único de emergencia de 31 días de los medicamentospara los cuales no hayan recibido aún un suministro de transición. Adicionalmente, el farmacéutico quesurte la receta deberá comunicarse con el Centro de Ayuda para Farmacias con el fin de recibirinstrucciones apropiadas para surtir una receta requerida debido a un cambio en el nivel de la atención.xii

Si desea más informaciónSi desea información detallada sobre su cobertura de medicamentos recetados de Simply HealthcarePlans, Inc., consulte su Evidencia de Cobertura y demás documentos del plan.Si tiene preguntas sobre Simply Healthcare Plans, Inc., comuníquese con el Departamento de Serviciospara Afiliados llamando al 1-877-577-0115. Los usuarios con TTY/TDD deben marcar 711. Estamosdisponibles los 7 días de la semana de 8 a.m. a 8 p.m. a partir del 15 de Febrero hasta el 30 deseptiembre puede dejarnos un mensaje de voz después del horario de trabajo, los sábados, domingos ydías festivos y devolveremos la llamada al siguiente día hábil. O visite www.mysimplymedicare.com.Si tiene alguna pregunta general sobre la cobertura de medicamentos recetados de Medicare,comuníquese con Medicare llamando al 1-800-MEDICARE (1-800-633-4227). Se atiende las 24 horasdel día, los 7 días de la semana. Las personas con impedimentos auditivos pueden llamar al 1-877-486-2048 o visitar la página www.medicare.gov.Formulario de Simply Healthcare Plans, Inc.El formulario que se ofrece a continuación proporciona información de cobertura de algunos de losmedicamentos cubiertos por Simply Healthcare Plans, Inc. Si tiene problemas para encontrar sumedicamento en la lista, diríjase al Índice que comienza en la página 53.En la primera columna del diagrama se incluye el nombre del medicamento. Los medicamentos demarca están con letras mayúsculas (por ejemplo, LIPITOR 10 MG), y los medicamentos genéricos seincluyen con letras minúsculas en itálica (por ejemplo, pravastatin sodium 10 mg).La información en la columna de requisitos y límites indica si Simply Healthcare Plans, Inc. tiene algúnrequisito especial para dar cobertura a su medicamento.Listado De AbreviacionesB/DEDGCGC DAutorización Previa B v D. Dependiendo de las circunstancias, este medicamento podría tenercobertura bajo la Parte B o la Parte D de Medicare. Puede ser necesario enviar informaciónsobre el uso del medicamento y la situación específica para tomar una determinación.Este medicamento recetado por lo general no está cubierto en un Plan de MedicamentosRecetados de Medicare. La cantidad que usted paga cuando le surten una receta de estemedicamento no se toma en cuenta en su costo total de medicamentos (es decir, la cantidad quepaga no le ayuda a reunir los requisitos para la cobertura por catástrofe). Además, si estárecibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar por este medicamento.Cobertura adicional. Proporcionamos cobertura adicional de este medicamento recetado durantela brecha en la cobertura. Consulte nuestra Evidencia de Cobertura para obtener másinformación sobre esta cobertura.Cobertura adicional durante la brecha para ciertos planes. Proporcionamos cobertura adicionalde este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia dexiii

Cobertura para obtener más información sobre esta cobertura.LAMOPAQLSTDisposición Limitada. Este medicamento recetado solo podría estar disponible en algunasfarmacias. Si desea más información, consulte su Directorio de proveedores/Farmacias ocomuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Seatiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711.Este medicamento recetado puede obtenerse mediante pedido por correo.Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtengaautorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener laaprobación de Simply Healthcare Plans, Inc. antes de adquirir su medicamento. Si no obtieneaprobación, Simply Healthcare Plans, Inc. podría no cubrir el medicamento.Límites en la cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. establecelímites en las cantidades que cubre. Por ejemplo, Simply Healthcare Plans, Inc. proporciona 30tabletas por receta del medicamento Celebrex en capsulas de 100mg. Esto puede ser adicional alsuministro estándar de un mes o tres meses.Terapia por fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebeprimero ciertos medicamentos para el tratamiento de su condición médica antes que cubramosotros medicamentos indicados para ese tratamiento. Por ejemplo, si los medicamentos A y Bestán indicados para el tratamiento de su condición médica, es posible que Simply HealthcarePlans, Inc. no cubra el medicamento B si usted no prueba primero el medicamento A. Si elmedicamento A no es efectivo, entonces Simply Healthcare Plans, Inc. cubrirá el medicamentoB.xiv

Nivel delMedicamentoen elFormularioNombre del Nivel enel FormularioCopago/Coaseguro enFarmacias Minoristas yFarmacias con Pedidospor Correo1 Genérico Preferido Copago mas bajo2 Genérico No-Preferido Copago bajo345Medicamento de MarcaPreferidoMedicamento de MarcaNo- PreferidoMedicamentosespecialesCopago MedianoAlto CopagoAlto CoaseguroExplicaciónCopago por un suministrode 30 días por receta orelleno en farmaciasminoristas o copago por unsuministro de 90 días porreceta o relleno para pedidopor correo.Copago por un suministrode 30 días por receta orelleno en farmaciasminoristas o copago por unsuministro de 90 días porreceta o relleno para pedidopor correo.Copago por un suministrode 30 días por receta orelleno en farmaciasminoristas o copago por unsuministro de 90 días porreceta o relleno para pedidopor correo.Copago por un suministrode 30 días por receta orelleno en farmaciasminoristas.Coaseguro por unsuministro de 30 días porreceta o relleno enfarmacias minoristas.Nota: Por favor consulte nuestra Evidencia de Cobertura para obtener más información sobre suscopagos y la disponibilidad de un suministro de 90 días en farmacias minoristas y pedidos por correode medicamentos en los Niveles 1-3. Afiliados recibiendo ayuda adicional pagaran el copagoestablecido en la Clausula para el subsidio por ingreso limitado. Por favor refiérase a su Clausulapara el subsidio por ingreso limitado o llame a nuestro Departamento de Servicios para el afiliado al1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Losusuarios con TTY deben marcar 711.xv

Drug NameDrugTier Requirements/LimitsAnalgesicsAnalgesicsacetaminophen/caffeine/dihydrocodeine bitartrate tabs 2 QL (165 EA per 30 days) MO GC712.8mg; 60mg; 32mgacetaminophen/codeine #3 tabs 300mg; 30mg 1 QL (360 EA per 30 days) MO GCacetaminophen/codeine soln 120mg/5ml; 12mg/5ml 1 QL (3240 ML per 30 days) MOGCacetaminophen/codeine tabs 300mg; 15mg 1 QL (390 EA per 30 days) MO GCacetaminophen/codeine tabs 300mg; 60mg 1 QL (360 EA per 30 days) MO GCARTHROTEC 50 TABS 50MG; 200MCG 4ARTHROTEC 75 TABS 75MG; 200MCG 4ascomp/codeine caps 325mg; 50mg; 40mg; 30mg 2 MO GCbutalbital/acetaminophen/caffeine/codeine caps 325mg; 2 QL (180 EA per 30 days) MO GC50mg; 40mg; 30mgBUTRANS PTWK 10MCG/HR 4 QL (4 EA per 28 days)BUTRANS PTWK 20MCG/HR 4 QL (4 EA per 28 days)BUTRANS PTWK 5MCG/HR 4 QL (10 EA per 30 days)carisoprodol/aspirin/codeine tabs 325mg; 200mg; 16mg 2 PA MO GCcarisoprodol/aspirin tabs 325mg; 200mg 2 PA MO GCco-gesic tabs 500mg; 5mg 1 QL (240 EA per 30 days) MO GCendocet tabs 325mg; 10mg 2 QL (360 EA per 30 days) MO GCendocet tabs 325mg; 5mg 1 QL (360 EA per 30 days) MO GCendocet tabs 325mg; 7.5mg 2 QL (360 EA per 30 days) MO GCendocet tabs 500mg; 7.5mg 2 QL (240 EA per 30 days) MO GCendocet tabs 650mg; 10mg 2 QL (180 EA per 30 days) MO GCendodan tabs 325mg; 4.835mg 1 MO GChydrocodone bitartrate/acetaminophen soln325mg/15ml; 7.5mg/15ml1 QL (5520 ML per 30 days) MOGChydrocodone bitartrate/acetaminophen tabs 300mg; 1 QL (180 EA per 30 days) MO GC10mghydrocodone bitartrate/acetaminophen tabs 300mg; 5mg1 QL (360 EA per 30 days) MO GChydrocodone bitartrate/acetaminophen tabs 750mg; 1 QL (150 EA per 30 days) MO GC10mghydrocodone/acetaminophen soln 500mg/15ml;7.5mg/15ml1 QL (3600 ML per 30 days) MOGChydrocodone/acetaminophen tabs 325mg; 10mg 1 QL (180 EA per 30 days) MO GChydrocodone/acetaminophen tabs 325mg; 5mg 1 QL (360 EA per 30 days) MO GChydrocodone/acetaminophen tabs 325mg; 7.5mg 1 QL (240 EA per 30 days) MO GChydrocodone/acetaminophen tabs 500mg; 10mg 1 QL (180 EA per 30 days) 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 1

Drug NameDrugTier Requirements/Limitshydrocodone/acetaminophen tabs 500mg; 2.5mg 1 QL (240 EA per 30 days) MO GChydrocodone/acetaminophen tabs 500mg; 5mg 1 QL (240 EA per 30 days) MO GChydrocodone/acetaminophen tabs 500mg; 7.5mg 1 QL (180 EA per 30 days) MO GChydrocodone/acetaminophen tabs 650mg; 10mg 1 QL (180 EA per 30 days) MO GChydrocodone/acetaminophen tabs 650mg; 7.5mg 1 QL (180 EA per 30 days) MO GChydrocodone/acetaminophen tabs 660mg; 10mg 1 QL (180 EA per 30 days) MO GChydrocodone/acetaminophen tabs 750mg; 7.5mg 1 QL (150 EA per 30 days) MO GChydrocodone/ibuprofen tabs 7.5mg; 200mg 1 MO GCorphenadrine/asa/caffeine tabs 385mg; 30mg; 25mg 2 PA MO GCoxycodone/acetaminophen caps 500mg; 5mg 1 QL (240 EA per 30 days) MO GCoxycodone/acetaminophen tabs 325mg; 10mg 2 QL (360 EA per 30 days) MO GCoxycodone/acetaminophen tabs 325mg; 2.5mg 2 QL (360 EA per 30 days) MO GCoxycodone/acetaminophen tabs 325mg; 5mg 1 QL (360 EA per 30 days) MO GCoxycodone/acetaminophen tabs 325mg; 7.5mg 2 QL (360 EA per 30 days) MO GCoxycodone/acetaminophen tabs 500mg; 7.5mg 2 QL (240 EA per 30 days) MO GCoxycodone/acetaminophen tabs 650mg; 10mg 2 QL (180 EA per 30 days) MO GCoxycodone/aspirin tabs 325mg; 4.835mg 1 MO GCpentazocine/acetaminophen tabs 650mg; 25mg 1 QL (180 EA per 30 days) PA MOGCpentazocine/naloxone hcl tabs 0.5mg; 50mg 1 MO GCreprexain tabs 10mg; 200mg 1 MO GCROXICET SOLN 325MG/5ML; 5MG/5ML 3 QL (1800 ML per 30 days) MOstagesic caps 500mg; 5mg 1 QL (240 EA per 30 days) MO GCSYNALGOS-DC CAPS 356.4MG; 30MG; 16MG 4tramadol hydrochloride/acetaminophen tabs 325mg; 1 QL (240 EA per 30 days) MO GC37.5mgNonsteroidal Anti-inflammatory DrugsCELEBREX CAPS 100MG 4 QL (30 EA per 30 days) STCELEBREX CAPS 200MG 4 QL (60 EA per 30 days) STCELEBREX CAPS 400MG 4 QL (60 EA per 30 days) STCELEBREX CAPS 50MG 4 QL (60 EA per 30 days) STdiclofenac potassium tabs 50mg 1 MO GCdiclofenac sodium dr tbec 25mg 1 MO GCdiclofenac sodium dr tbec 50mg 1 MO GCdiclofenac sodium dr tbec 75mg 1 MO GCdiclofenac sodium er tb24 100mg 1 MO GCdiclofenac sodium/misoprostol tabs 50mg; 200mcg 2diclofenac sodium/misoprostol tabs 75mg; 200mcg 2PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 2

Drug NameDrugTier Requirements/Limitsdiflunisal tabs 500mg 1 MO GCetodolac er tb24 400mg 2 MO GCetodolac er tb24 500mg 2 MO GCetodolac er tb24 600mg 2 MO GCetodolac caps 200mg 1 MO GCetodolac caps 300mg 2etodolac caps 300mg 2etodolac caps 300mg 2etodolac tabs 400mg 1 MO GCetodolac tabs 500mg 1 MO GCfenoprofen calcium tabs 600mg 1 MO GCFLECTOR PTCH 1.3% 4flurbiprofen tabs 100mg 1 MO GCflurbiprofen tabs 50mg 1 MO GCibuprofen susp 100mg/5ml 1 MO GCibuprofen tabs 400mg 1 MO GCibuprofen tabs 600mg 1 MO GCibuprofen tabs 800mg 1 MO GCINDOCIN SUSP 25MG/5ML 4indomethacin er cpcr 75mg 1 MO GCindomethacin caps 25mg 1 MO GCindomethacin caps 50mg 1 MO GCketoprofen er cp24 200mg 2 MO GCketoprofen caps 50mg 1 MO GCketoprofen caps 75mg 1 MO GCketorolac tromethamine inj 15mg/ml 1 QL (20 ML per 30 days) PA MOGCketorolac tromethamine inj 30mg/ml 1 QL (20 ML per 30 days) PA MOGCketorolac tromethamine tabs 10mg 1 QL (20 EA per 30 days) PA MOGCmeclofenamate sodium caps 100mg 2 MO GCMECLOFENAMATE SODIUM CAPS 50MG 4mefenamic acid caps 250mg 2 MO GCmeloxicam susp 7.5mg/5ml 2 MO GCmeloxicam tabs 15mg 1 MO GCmeloxicam tabs 7.5mg 1 MO GCnabumetone tabs 500mg 1 MO GCnabumetone tabs 750mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 3

Drug NameDrugTier Requirements/Limitsnaproxen dr tbec 375mg 1 MO GCnaproxen dr tbec 500mg 1 MO GCnaproxen sodium tabs 275mg 1 MO GCnaproxen sodium tabs 550mg 1 MO GCnaproxen susp 125mg/5ml 1 MO GCnaproxen tabs 250mg 1 MO GCnaproxen tabs 375mg 1 MO GCoxaprozin tabs 600mg 1 MO GCoxycodone/ibuprofen tabs 400mg; 5mg 2 MO GCPENNSAID SOLN 1.5% 4piroxicam caps 10mg 1 MO GCpiroxicam caps 20mg 1 MO GCsulindac tabs 150mg 1 MO GCsulindac tabs 200mg 1 MO GCtolmetin sodium caps 400mg 2 MO GCtolmetin sodium tabs 200mg 2 MO GCtolmetin sodium tabs 600mg 2 MO GCOpioid Analgesics, Long-actingABSTRAL SUBL 100MCG 4 QL (120 EA per 30 days) ST PAABSTRAL SUBL 200MCG 5 QL (120 EA per 30 days) ST PAABSTRAL SUBL 800MCG 5 QL (120 EA per 30 days) ST PAastramorph inj 0.5mg/ml 1 MO GCEXALGO TB24 12MG 4 QL (60 EA per 30 days)EXALGO TB24 16MG 5 QL (120 EA per 30 days)EXALGO TB24 8MG 4 QL (60 EA per 30 days)FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 5 QL (120 EA per 30 days) PA1200MCGFENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 5 QL (120 EA per 30 days) PA1600MCGFENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 5 QL (120 EA per 30 days) PA200MCGFENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 5 QL (120 EA per 30 days) PA400MCGFENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 5 QL (120 EA per 30 days) PA600MCGFENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 5 QL (120 EA per 30 days) PA800MCGfentanyl pt72 100mcg/hr 2 QL (30 EA per 30 days) MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 4

Drug NameDrugTier Requirements/Limitsfentanyl pt72 12mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 25mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 50mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 75mcg/hr 2 QL (15 EA per 30 days) MO GCFENTORA TABS 200MCG 5 QL (120 EA per 30 days) ST PAFENTORA TABS 400MCG 5 QL (120 EA per 30 days) ST PAFENTORA TABS 800MCG 5 QL (120 EA per 30 days) ST PAmethadone hcl soln 5mg/5ml 1 MO GCmethadone hcl tabs 10mg 1 MO GCmethadone hcl tabs 5mg 1 MO GCmorphine sulfate er cp24 100mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 20mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 30mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 50mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 60mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 80mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 100mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 15mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 200mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 30mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 60mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate soln 10mg/5ml 1 MO GCmorphine sulfate soln 20mg/5ml 1 MO GCmorphine sulfate soln 20mg/ml 1 MO GCmorphine sulfate tabs 15mg 1 MO GCmorphine sulfate tabs 30mg 1 MO GCMS CONTIN TB12 100MG 4 QL (60 EA per 30 days)MS CONTIN TB12 15MG 4 QL (60 EA per 30 days)MS CONTIN TB12 30MG 4 QL (60 EA per 30 days)MS CONTIN TB12 60MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 100MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 150MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 200MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 250MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 50MG 4 QL (300 EA per 30 days)ONSOLIS FILM 200MCG 5 QL (120 EA per 30 days) ST PAONSOLIS FILM 400MCG 5 QL (90 EA per 30 days) ST PAOPANA ER (CRUSH RESISTANT) TB12 10MG 3 QL (60 EA per 30 days) MOOPANA ER (CRUSH RESISTANT) TB12 20MG 3 QL (60 EA per 30 days) MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 5

Drug NameDrugTier Requirements/LimitsOPANA ER (CRUSH RESISTANT) TB12 30MG 3 QL (60 EA per 30 days) MOOPANA ER (CRUSH RESISTANT) TB12 40MG 5 QL (60 EA per 30 days)OPANA ER (CRUSH RESISTANT) TB12 5MG 3 QL (60 EA per 30 days) MOOXYCONTIN TB12 10MG 4 QL (60 EA per 30 days)OXYCONTIN TB12 15MG 4 QL (60 EA per 30 days)OXYCONTIN TB12 20MG 4 QL (60 EA per 30 days)OXYCONTIN TB12 30MG 4 QL (60 EA per 30 days)OXYCONTIN TB12 40MG 4 QL (60 EA per 30 days)OXYCONTIN TB12 60MG 4 QL (60 EA per 30 days)OXYCONTIN TB12 80MG 5 QL (120 EA per 30 days)oxymorphone hydrochloride er tb12 15mg 2 QL (60 EA per 30 days) MO GCtramadol hcl er tb24 100mg 2 MO GCtramadol hcl er tb24 200mg 2 MO GCtramadol hcl er tb24 300mg 2 MO GCOpioid Analgesics, Short-actingbutorphanol tartrate inj 2mg/ml 2 MO GCbutorphanol tartrate soln 10mg/ml 2 MO GCcodeine sulfate tabs 30mg 2 MO GCCODEINE SULFATE TABS 60MG 3 MODILAUDID-5 LIQD 1MG/ML 4hydromorphone hcl inj 500mg/50ml 1 MO GChydromorphone hcl tabs 2mg 1 MO GChydromorphone hcl tabs 4mg 1 MO GChydromorphone hcl tabs 8mg 1 MO GCmeperidine hcl inj 100mg/ml 2 PA MO GCmeperidine hcl inj 25mg/ml 2 PA MO GCmeperidine hcl inj 50mg/ml 2 PA MO GCmeperitab tabs 100mg 2 PA MO GCmeperitab tabs 50mg 2 PA MO GCnalbuphine hcl inj 10mg/ml 1 MO GCnalbuphine hcl inj 20mg/ml 1 MO GCNUCYNTA TABS 100MG 4 QL (180 EA per 30 days)NUCYNTA TABS 50MG 4 QL (180 EA per 30 days)NUCYNTA TABS 75MG 4 QL (180 EA per 30 days)oxycodone hcl caps 5mg 1 MO GCoxycodone hcl conc 20mg/ml 2 MO GCoxycodone hcl tabs 15mg 1 MO GCoxycodone hcl tabs 30mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 6

Drug NameDrugTier Requirements/Limitsoxycodone hcl tabs 5mg 1 MO GCoxymorphone hydrochloride tabs 10mg 2 MO GCoxymorphone hydrochloride tabs 5mg 2 MO GCtramadol hcl tabs 50mg 1 MO GCAnestheticsLocal Anestheticslidocaine hcl jelly gel 2% 1 MO GClidocaine hcl jelly gel 2% 1 MO GClidocaine hcl inj 1% 1 MO GClidocaine hcl soln 4% 1 MO GClidocaine viscous soln 2% 1 MO GClidocaine/prilocaine crea 2.5%; 2.5% 2 B/D MO GClidocaine oint 5% 1 B/D MO GCLIDODERM PTCH 5% 4Anti-Addiction/ Substance Abuse Treatment AgentsAlcohol Deterrents/ Anti-cravingCAMPRAL TBEC 333MG 4disulfiram tabs 250mg 2 MO GCdisulfiram tabs 500mg 2 MO GCnaltrexone hcl tabs 50mg 2 MO GCAnti-Addiction/ Substance Abuse Treatment AgentsSUBOXONE FILM 2MG; 0.5MG 4 QL (90 EA per 30 days)SUBOXONE FILM 8MG; 2MG 4 QL (90 EA per 30 days)SUBOXONE SUBL 2MG; 0.5MG 4 QL (90 EA per 30 days)SUBOXONE SUBL 8MG; 2MG 4 QL (90 EA per 30 days)Opioid Antagonistsbuprenorphine hcl subl 2mg 2 MO GCbuprenorphine hcl subl 8mg 2 MO GCnaloxone hcl inj 1mg/ml 1 MO GCSmoking Cessation AgentsNICOTROL NS SOLN 10MG/ML 3 MOAnti-inflammatory AgentsNonsteroidal Anti-inflammatory Drugsnaproxen tabs 500mg 1 MO GCAntibacterialsAminoglycosidesamikacin sulfate inj 1gm/4ml 1 MO GCgentak oint 0.3% 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 7

Drug NameDrugTier Requirements/Limitsgentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 1 MO GC0.9%gentamicin sulfate/0.9% sodium chloride inj 1mg/ml; 1 MO GC0.9%gentamicin sulfate crea 0.1% 1 MO GCgentamicin sulfate inj 10mg/ml 1 MO GCgentamicin sulfate inj 40mg/ml 1 MO GCgentamicin sulfate oint 0.1% 1 MO GCgentamicin sulfate soln 0.3% 1 MO GCisotonic gentamicin inj 0.8mg/ml; 0.9% 1 MO GCKANAMYCIN SULFATE INJ 333MG/ML 4neomycin sulfate tabs 500mg 1 MO GCparomomycin sulfate caps 250mg 1 MO GCTOBI NEBU 300MG/5ML 4TOBRADEX OINT 0.1%; 0.3% 4tobramycin sulfate inj 10mg/ml 1 MO GCtobramycin sulfate inj 80mg/2ml 1 MO GCtobramycin sulfate soln 0.3% 1 MO GCTOBREX OINT 0.3% 4Antibacterials, Otheracetic acid soln 2% 1 MO GCalcohol preps pads 1 MO GCALTABAX OINT 1% 4bacitracin oint 500unit/gm 2 MO GCBACTROBAN NASAL OINT 2% 4BACTROBAN CREA 2% 4CHANTIX STARTING MONTH PAK TABS 0 4 QL (53 EA per 28 days) PACHANTIX TABS 0.5MG 4 QL (60 EA per 30 days) PACHANTIX TABS 1MG 4 QL (56 EA per 30 days) PACLEOCIN PEDIATRIC GRANULES SOLR 75MG/5ML 4CLEOCIN SUPP 100MG 4clindamycin hcl caps 150mg 1 MO GCclindamycin hcl caps 300mg 1 MO GCclindamycin phosphate add-vantage inj 150mg/ml 1 MO GCclindamycin phosphate crea 2% 1 MO GCclindamycin phosphate foam 1% 2 MO GCclindamycin phosphate gel 1% 1 MO GCclindamycin phosphate lotn 1% 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 8

Drug NameDrugTier Requirements/Limitsclindamycin phosphate soln 1% 1 MO GCclindamycin phosphate swab 1% 1 MO GCCUBICIN INJ 500MG 5LINCOCIN INJ 300MG/ML 3 MOMACRODANTIN CAPS 25MG 4 PAmethenamine hippurate tabs 1gm 2 MO GCMETROGEL GEL 1% 4metronidazole in nacl 0.79% inj 500mg/100ml; 0.79% 2 MO GCmetronidazole vaginal gel 0.75% 1 MO GCmetronidazole caps 375mg 2 MO GCmetronidazole crea 0.75% 1 MO GCmetronidazole gel 0.75% 1 MO GCmetronidazole lotn 0.75% 1 MO GCmetronidazole tabs 250mg 1 MO GCmetronidazole tabs 500mg 1 MO GCMONUROL PACK 5.631GM 4mupirocin oint 2% 1 MO GCnitrofurantoin macrocrystalline caps 50mg 2 PA MO GCnitrofurantoin monohydrate caps 100mg 2 PA MO GCNITROFURANTOIN SUSP 25MG/5ML 4SSD CREA 1% 3SULFAMYLON CREA 85MG/GM 4THERMAZENE CREA 1% 3trimethoprim tabs 100mg 1 MO GCTYGACIL INJ 50MG 4VANCOMYCIN HCL CAPS 125MG 5VANCOMYCIN HCL CAPS 250MG 5vancomycin hcl inj 1000mg 2 B/D MO GCvancomycin hcl inj 10gm 2 B/D MO GCvancomycin hcl inj 500mg 2 B/D MO GCvandazole gel 0.75% 1 MO GCXIFAXAN TABS 200MG 4 QL (9 EA per 30 days)XIFAXAN TABS 550MG 5 QL (60 EA per 30 days)ZYVOX INJ 2MG/ML 5 PAZYVOX SUSR 100MG/5ML 5 QL (1800 ML per 30 days) PAZYVOX TABS 600MG 5 QL (56 EA per 30 days) PAAntibacterialsCOLISTIMETHATE SODIUM INJ 150MG 4 B/DSYNERCID INJ 350MG; 150MG 5PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 9

Drug NameDrugTier Requirements/LimitsBeta-lactam, Cephalosporinscefaclor caps 250mg 1 MO GCcefaclor caps 500mg 1 MO GCcefadroxil caps 500mg 2 MO GCcefadroxil susr 250mg/5ml 2 MO GCcefadroxil susr 500mg/5ml 2 MO GCcefadroxil tabs 1gm 2 MO GCcefazolin sodium inj 10gm 2 MO GCcefazolin sodium inj 1gm 2 MO GCcefazolin sodium inj 500mg 2 MO GCcefdinir caps 300mg 2 MO GCcefdinir susr 125mg/5ml 2 MO GCcefdinir susr 250mg/5ml 2 MO GCcefepime inj 1gm 2 MO GCcefepime inj 2gm 2 MO GCcefotaxime sodium inj 10gm 2 MO GCcefotaxime sodium inj 1gm 2 MO GCcefotaxime sodium inj 2gm 2 MO GCcefotetan inj 2gm 2 MO GCcefoxitin sodium inj 1gm; 4% 2 MO GCcefoxitin sodium inj 2gm 2 MO GCcefpodoxime proxetil susr 100mg/5ml 2 MO GCcefpodoxime proxetil susr 50mg/5ml 2 MO GCcefpodoxime proxetil tabs 100mg 2 MO GCcefpodoxime proxetil tabs 200mg 2 MO GCcefprozil susr 125mg/5ml 2 MO GCcefprozil susr 250mg/5ml 2 MO GCcefprozil tabs 250mg 2 MO GCcefprozil tabs 500mg 2 MO GCceftazidime inj 1gm 2 MO GCceftazidime inj 2gm 2 MO GCceftriaxone sodium inj 10gm 2 MO GCceftriaxone sodium inj 250mg 2 MO GCceftriaxone sodium inj 500mg 2 MO GCcefuroxime axetil tabs 250mg 2 MO GCcefuroxime axetil tabs 500mg 2 MO GCcefuroxime sodium inj 1.5gm 2 MO GCcefuroxime sodium inj 7.5gm 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 10

Drug NameDrugTier Requirements/Limitscefuroxime sodium inj 750mg 2 MO GCcephalexin caps 250mg 1 MO GCcephalexin caps 500mg 1 MO GCcephalexin susr 125mg/5ml 1 MO GCcephalexin susr 250mg/5ml 1 MO GCSPECTRACEF TABS 400MG 4SUPRAX CHEW 100MG 4SUPRAX CHEW 200MG 4SUPRAX SUSR 100MG/5ML 4SUPRAX TABS 400MG 4TEFLARO INJ 400MG 4 B/DBeta-lactam, Otheraztreonam inj 1gm 2 MO GCCAYSTON SOLR 75MG 5 QL (84 ML per 28 days) PADORIBAX INJ 500MG 4imipenem/cilastatin inj 250mg; 250mg 2 MO GCimipenem/cilastatin inj 500mg; 500mg 2 MO GCINVANZ INJ 1GM 4meropenem inj 500mg 2 MO GCBeta-lactam, Penicillinsamoxicillin/clavulanate potassium er tb12 1000mg; 2 MO GC62.5mgamoxicillin/clavulanate potassium chew 200mg; 28.5mg 2 MO GCamoxicillin/clavulanate potassium chew 400mg; 57mg 2 MO GCamoxicillin/clavulanate potassium susr 250mg/5ml; 2 MO GC62.5mg/5mlamoxicillin/clavulanate potassium susr 400mg/5ml; 2 MO GC57mg/5mlamoxicillin/clavulanate potassium susr 600mg/5ml; 2 MO GC42.9mg/5mlamoxicillin/clavulanate potassium tabs 250mg; 125mg 2 MO GCamoxicillin/potassium clavulanate susr 200mg/5ml; 2 MO GC28.5mg/5mlamoxicillin/potassium clavulanate tabs 500mg; 125mg 2 MO GCamoxicillin/potassium clavulanate tabs 875mg; 125mg 2 MO GCamoxicillin caps 250mg 1 MO GCamoxicillin caps 500mg 1 MO GCamoxicillin chew 250mg 1 MO GCamoxicillin susr 125mg/5ml 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 11

Drug NameDrugTier Requirements/Limitsamoxicillin susr 200mg/5ml 1 MO GCamoxicillin susr 250mg/5ml 1 MO GCamoxicillin susr 400mg/5ml 1 MO GCamoxicillin tabs 500mg 1 MO GCamoxicillin tabs 875mg 1 MO GCampicillin sodium inj 125mg 1 MO GCampicillin sodium inj 1gm 1 MO GCampicillin-sulbactam inj 10gm; 5gm 2 MO GCampicillin-sulbactam inj 2gm; 1gm 2 MO GCampicillin caps 250mg 1 MO GCampicillin caps 500mg 1 MO GCBICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML 4BICILLIN L-A INJ 1200000UNIT/2ML 4BICILLIN L-A INJ 2400000UNIT/4ML 4BICILLIN L-A INJ 600000UNIT/ML 4dicloxacillin sodium caps 250mg 1 MO GCdicloxacillin sodium caps 500mg 1 MO GCnafcillin sodium inj 1gm 1 MO GCPENICILLIN G POTASSIUM IN ISO-OSMOTIC 3 MODEXTROSE INJ 0; 60000UNIT/MLpenicillin g potassium inj 5mu 1 MO GCpenicillin g sodium inj 5000000unit 1 MO GCpenicillin v potassium solr 125mg/5ml 1 MO GCpenicillin v potassium solr 250mg/5ml 1 MO GCpenicillin v potassium tabs 250mg 1 MO GCpenicillin v potassium tabs 500mg 1 MO GCpiperacillin sodium/tazobactam sodium inj 3gm; 0.375gm2 MO GCMacrolidesAKNE-MYCIN OINT 2% 4AZASITE SOLN 1% 4azithromycin inj 500mg 2 MO GCazithromycin susr 100mg/5ml 2 MO GCazithromycin susr 200mg/5ml 2 MO GCazithromycin tabs 250mg 2 MO GCazithromycin tabs 500mg 2 MO GCazithromycin tabs 600mg 2 MO GCclarithromycin er tb24 500mg 2 MO GCclarithromycin susr 125mg/5ml 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 12

Drug NameDrugTier Requirements/Limitsclarithromycin susr 250mg/5ml 2 MO GCclarithromycin tabs 250mg 2 MO GCclarithromycin tabs 500mg 2 MO GCDIFICID TABS 200MG 4 PAE.E.S. 400 TABS 400MG 3 MOE.E.S. GRANULES SUSR 200MG/5ML 3 MOERY-TAB TBEC 250MG 4ERY-TAB TBEC 333MG 4ERY-TAB TBEC 500MG 4ery pads 2% 2 MO GCERYPED 200 SUSR 200MG/5ML 4ERYPED 400 SUSR 400MG/5ML 4ERYTHROCIN STEARATE TABS 250MG 3 MOerythromycin ethylsuccinate tabs 400mg 1 MO GCerythromycin gel 2% 1 MO GCerythromycin oint 5mg/gm 1 MO GCerythromycin soln 2% 1 MO GCZITHROMAX PACK 1GM 4QuinolonesAVELOX INJ 400MG/250ML; 0.8% 4AVELOX TABS 400MG 4BESIVANCE SUSP 0.6% 4CILOXAN OINT 0.3% 4ciprofloxacin er tb24 1000mg; 0 2 MO GCciprofloxacin er tb24 500mg; 0 2 MO GCciprofloxacin hcl soln 0.3% 1 MO GCciprofloxacin hcl tabs 100mg 1 MO GCciprofloxacin hcl tabs 250mg 1 MO GCciprofloxacin hcl tabs 500mg 1 MO GCciprofloxacin hcl tabs 750mg 1 MO GCciprofloxacin inj 400mg/40ml 2 MO GCCIPRO SUSR 500MG/5ML 4FACTIVE TABS 320MG 4levofloxacin in d5w inj 5%; 500mg/100ml 1 MO GClevofloxacin inj 25mg/ml 1 MO GClevofloxacin soln 0.5% 1 MO GClevofloxacin soln 25mg/ml 1 MO GClevofloxacin tabs 250mg 1 MO GClevofloxacin tabs 500mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 13

Drug NameDrugTier Requirements/Limitslevofloxacin tabs 750mg 1 MO GCMOXEZA SOLN 0.5% 4ofloxacin soln 0.3% 1 MO GCofloxacin soln 0.3% 1 MO GCofloxacin tabs 200mg 2 MO GCofloxacin tabs 300mg 2 MO GCofloxacin tabs 400mg 2 MO GCVIGAMOX SOLN 0.5% 4ZYMAXID SOLN 0.5% 4Sulfonamidessilver sulfadiazine crea 1% 1 MO GCsodium sulfacetamide soln 10% 1 MO GCsulfacetamide sodium susp 10% 2 MO GCsulfadiazine tabs 500mg 1 MO GCsulfamethoxazole/trimethoprim ds tabs 800mg; 160mg 1 MO GCsulfamethoxazole/trimethoprim inj 400mg/5ml; 80mg/5ml1 MO GCsulfamethoxazole/trimethoprim susp 200mg/5ml; 1 MO GC40mg/5mlsulfamethoxazole/trimethoprim tabs 400mg; 80mg 1 MO GCTetracyclinesDEMECLOCYCLINE HCL TABS 150MG 4DEMECLOCYCLINE HCL TABS 300MG 4doxycycline hyclate caps 100mg 1 MO GCdoxycycline hyclate caps 50mg 1 MO GCdoxycycline hyclate inj 100mg 2 MO GCdoxycycline hyclate tabs 100mg 1 MO GCdoxycycline hyclate tabs 20mg 2 MO GCdoxycycline hyclate tbec 150mg 2 MO GCdoxycycline monohydrate tabs 150mg 2 MO GCdoxycycline monohydrate tabs 50mg 2 MO GCdoxycycline caps 75mg 2 MO GCminocycline hcl caps 100mg 1 MO GCminocycline hcl caps 75mg 1 MO GCtetracycline hcl caps 250mg 1 MO GCtetracycline hcl caps 500mg 1 MO GCAnticonvulsantsAnticonvulsants, Otherlevetiracetam er tb24 500mg 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 14

Drug NameDrugTier Requirements/Limitslevetiracetam er tb24 750mg 2 MO GClevetiracetam inj 500mg/5ml 2 MO GClevetiracetam soln 100mg/ml 1 MO GClevetiracetam tabs 1000mg 1 MO GClevetiracetam tabs 250mg 1 MO GClevetiracetam tabs 500mg 1 MO GClevetiracetam tabs 750mg 1 MO GCONFI TABS 10MG 4 QL (60 EA per 30 days)ONFI TABS 20MG 4 QL (60 EA per 30 days)ONFI TABS 5MG 4 QL (60 EA per 30 days)phenobarbital elix 20mg/5ml 1 QL (1500 ML per 30 days) PAMO GCphenobarbital tabs 100mg 1 QL (90 EA per 30 days) PA MOphenobarbital tabs 15mg 1 QL (90 EA per 30 days) PA MOphenobarbital tabs 16.2mg 1 QL (90 EA per 30 days) PA MOGCphenobarbital tabs 30mg 1 QL (90 EA per 30 days) PA MOGCphenobarbital tabs 32.4mg 1 QL (30 EA per 30 days) PA MOGCphenobarbital tabs 60mg 1 QL (90 EA per 30 days) PA MOphenobarbital tabs 64.8mg 1 QL (90 EA per 30 days) PA MOGCphenobarbital tabs 97.2mg 1 QL (90 EA per 30 days) PA MOGCPOTIGA TABS 200MG 5 PAPOTIGA TABS 300MG 5 PAPOTIGA TABS 400MG 5 PAPOTIGA TABS 50MG 5 PACalcium Channel Modifying AgentsCELONTIN CAPS 300MG 4ethosuximide caps 250mg 2 MO GCethosuximide soln 250mg/5ml 2 MO GCLYRICA CAPS 100MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 150MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 200MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 225MG 3 QL (60 EA per 30 days) MOLYRICA CAPS 25MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 300MG 3 QL (60 EA per 30 days) MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 15

Drug NameDrugTier Requirements/LimitsLYRICA CAPS 50MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 75MG 3 QL (90 EA per 30 days) MOLYRICA SOLN 20MG/ML 3 QL (450 ML per 30 days) MOzonisamide caps 100mg 1 MO GCzonisamide caps 25mg 1 MO GCzonisamide caps 50mg 1 MO GCGamma-aminobutyric Acid (GABA) Augmenting Agentsdivalproex sodium dr tbec 125mg 1 MO GCdivalproex sodium dr tbec 250mg 1 MO GCdivalproex sodium dr tbec 500mg 1 MO GCdivalproex sodium er tb24 250mg 1 MO GCdivalproex sodium er tb24 500mg 1 MO GCdivalproex sodium cpsp 125mg 1 MO GCgabapentin caps 100mg 1 MO GCgabapentin caps 300mg 1 MO GCgabapentin caps 400mg 1 MO GCgabapentin soln 250mg/5ml 1 MO GCgabapentin tabs 600mg 1 MO GCgabapentin tabs 800mg 1 MO GCGABITRIL TABS 12MG 4 QL (120 EA per 30 days)GABITRIL TABS 16MG 4 QL (60 EA per 30 days)GABITRIL TABS 2MG 4 QL (30 EA per 30 days)GABITRIL TABS 4MG 4 QL (60 EA per 30 days)primidone tabs 250mg 1 MO GCprimidone tabs 50mg 1 MO GCSABRIL PACK 500MG 5 QL (180 EA per 30 days)SABRIL TABS 500MG 4 QL (180 EA per 30 days) LASTAVZOR CPDR 500MG 4tiagabine hydrochloride tabs 2mg 2 QL (60 EA per 30 days)tiagabine hydrochloride tabs 4mg 2 QL (60 EA per 30 days)valproate sodium inj 100mg/ml 1 MO GCvalproic acid caps 250mg 1 MO GCvalproic acid syrp 250mg/5ml 1 MO GCGlutamate Reducing Agentsfelbamate susp 600mg/5ml 2 MO GCfelbamate tabs 400mg 2 MO GCfelbamate tabs 600mg 2 MO GCLAMICTAL ODT TBDP 100MG 4 QL (60 EA per 30 days)PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 16

Drug NameDrugTier Requirements/LimitsLAMICTAL ODT TBDP 200MG 4 QL (30 EA per 30 days)LAMICTAL ODT TBDP 25MG 4 QL (60 EA per 30 days)LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE4 QL (49 EA per 30 days)KIT 0LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT 4 QL (98 EA per 30 days)TAKING VALPROATE KIT 0LAMICTAL STARTER/TAKING VALPROATE KIT 25MG 4 QL (35 EA per 30 days)LAMICTAL XR KIT 0 4 QL (35 EA per 35 days)LAMICTAL XR TB24 100MG 4 QL (60 EA per 30 days)LAMICTAL XR TB24 200MG 4 QL (90 EA per 30 days)LAMICTAL XR TB24 250MG 4 QL (30 EA per 30 days)LAMICTAL XR TB24 25MG 4 QL (60 EA per 30 days)LAMICTAL XR TB24 50MG 4 QL (60 EA per 30 days)lamotrigine chew 25mg 1 MO GClamotrigine chew 5mg 1 MO GClamotrigine tabs 100mg 1 MO GClamotrigine tabs 150mg 1 MO GClamotrigine tabs 200mg 1 MO GClamotrigine tabs 25mg 1 MO GCtopiramate cpsp 15mg 1 MO GCtopiramate cpsp 25mg 1 MO GCtopiramate tabs 100mg 1 MO GCtopiramate tabs 200mg 1 MO GCtopiramate tabs 25mg 1 MO GCtopiramate tabs 50mg 1 MO GCSodium Channel AgentsBANZEL SUSP 40MG/ML 5 QL (2400 ML per 30 days)BANZEL TABS 200MG 4 QL (60 EA per 30 days)BANZEL TABS 400MG 5 QL (240 EA per 30 days)carbamazepine er tb12 200mg 2 MOcarbamazepine er tb12 400mg 2 MOcarbamazepine chew 100mg 1 MO GCcarbamazepine susp 100mg/5ml 1 MO GCDILANTIN INFATABS CHEW 50MG 4DILANTIN CAPS 100MG 4DILANTIN CAPS 30MG 4DILANTIN SUSP 125MG/5ML 4epitol tabs 200mg 1 MO GCEQUETRO CP12 100MG 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 17

Drug NameDrugTier Requirements/LimitsEQUETRO CP12 200MG 4 QL (240 EA per 30 days)EQUETRO CP12 300MG 4oxcarbazepine susp 300mg/5ml 2oxcarbazepine susp 60mg/ml 2oxcarbazepine tabs 150mg 1 MO GCoxcarbazepine tabs 300mg 1 MO GCoxcarbazepine tabs 600mg 1 MO GCPEGANONE TABS 250MG 4PHENYTEK CAPS 200MG 4PHENYTEK CAPS 300MG 4phenytoin infatabs chew 50mg 2phenytoin sodium extended caps 100mg 1 MO GCphenytoin sodium extended caps 200mg 1 MO GCphenytoin sodium extended caps 300mg 1 MO GCphenytoin susp 125mg/5ml 1 MO GCTEGRETOL-XR TB12 100MG 4TEGRETOL-XR TB12 200MG 4TEGRETOL-XR TB12 400MG 4TEGRETOL CHEW 100MG 4TEGRETOL SUSP 100MG/5ML 4TEGRETOL TABS 200MG 4TRILEPTAL SUSP 300MG/5ML 4VIMPAT INJ 200MG/20ML 4VIMPAT SOLN 10MG/ML 4 QL (1200 ML per 30 days)VIMPAT TABS 100MG 4 QL (60 EA per 30 days)VIMPAT TABS 150MG 4 QL (60 EA per 30 days)VIMPAT TABS 200MG 4 QL (60 EA per 30 days)VIMPAT TABS 50MG 4 QL (60 EA per 30 days)Antidementia AgentsAntidementia Agents, Otherergoloid mesylates tabs 1mg 2 MO GCCholinesterase Inhibitorsdonepezil hcl tabs 10mg 1 MO GCdonepezil hcl tabs 5mg 1 MO GCdonepezil hcl tbdp 10mg 1 MO GCdonepezil hcl tbdp 5mg 1 MO GCEXELON PT24 4.6MG/24HR 3 QL (30 EA per 30 days) MOEXELON PT24 9.5MG/24HR 3 QL (30 EA per 30 days) MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 18

Drug NameDrugTier Requirements/LimitsEXELON SOLN 2MG/ML 4galantamine hydrobromide cp24 16mg 2 MO GCgalantamine hydrobromide cp24 24mg 2 MO GCgalantamine hydrobromide cp24 8mg 2 MO GCgalantamine hydrobromide soln 4mg/ml 2 MO GCgalantamine hydrobromide tabs 12mg 2 MO GCgalantamine hydrobromide tabs 4mg 2 MO GCgalantamine hydrobromide tabs 8mg 2 MO GCrivastigmine tartrate caps 1.5mg 2 MO GCrivastigmine tartrate caps 3mg 2 MO GCrivastigmine tartrate caps 4.5mg 2 MO GCrivastigmine tartrate caps 6mg 2 MO GCN-methyl-D-aspartate (NMDA) Receptor AntagonistNAMENDA TITRATION PAK TABS 0 3 QL (49 EA per 30 days) MONAMENDA SOLN 10MG/5ML 3 QL (300 ML per 30 days) MONAMENDA TABS 10MG 3 QL (60 EA per 30 days) MONAMENDA TABS 5MG 3 QL (60 EA per 30 days) MOAntidepressantsAntidepressants, OtherAPLENZIN TB24 174MG 4 STAPLENZIN TB24 348MG 4 STAPLENZIN TB24 522MG 4 STbudeprion sr tb12 100mg 1 MO GCbudeprion sr tb12 150mg 1 MO GCbuproban tb12 150mg 1 MO GCbupropion hcl sr tb12 200mg 1 MO GCbupropion hcl tabs 100mg 1 MO GCbupropion hcl tabs 75mg 1 MO GCFORFIVO XL TB24 450MG 4 QL (30 EA per 30 days) MOmaprotiline hcl tabs 25mg 2 MO GCmaprotiline hcl tabs 50mg 2 MO GCmaprotiline hcl tabs 75mg 2 MO GCmirtazapine odt tbdp 30mg 1 MO GCmirtazapine odt tbdp 45mg 1 MO GCmirtazapine tabs 15mg 1 MO GCmirtazapine tabs 30mg 1 MO GCmirtazapine tabs 45mg 1 MO GCmirtazapine tabs 7.5mg 1 MO GCmirtazapine tbdp 15mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 19

Drug NameDrugTier Requirements/Limitsnefazodone hcl tabs 100mg 2 MO GCnefazodone hcl tabs 150mg 2 MO GCnefazodone hcl tabs 200mg 2 MO GCnefazodone hcl tabs 250mg 2 MO GCnefazodone hcl tabs 50mg 2 MO GCSEROQUEL XR TB24 150MG 4 QL (30 EA per 30 days)SEROQUEL XR TB24 200MG 4 QL (30 EA per 30 days)SEROQUEL XR TB24 300MG 4 QL (60 EA per 30 days)SEROQUEL XR TB24 400MG 4 QL (60 EA per 30 days) MOSEROQUEL XR TB24 50MG 4 QL (60 EA per 30 days)trazodone hcl tabs 100mg 1 MO GCtrazodone hcl tabs 150mg 1 MO GCtrazodone hcl tabs 300mg 2 MO GCtrazodone hcl tabs 50mg 1 MO GCVIIBRYD KIT 0 4 QL (60 EA per 30 days) STVIIBRYD TABS 10MG 4 QL (30 EA per 30 days) STVIIBRYD TABS 20MG 4 QL (30 EA per 30 days) STVIIBRYD TABS 40MG 4 QL (30 EA per 30 days) STAntidepressantschlordiazepoxide/amitriptyline tabs 12.5mg; 5mg 2 PA MO GCchlordiazepoxide/amitriptyline tabs 25mg; 10mg 2 PA MO GCperphenazine/amitriptyline tabs 10mg; 2mg 1 MO GCperphenazine/amitriptyline tabs 10mg; 4mg 1 MO GCperphenazine/amitriptyline tabs 25mg; 2mg 1 MO GCperphenazine/amitriptyline tabs 25mg; 4mg 1 MO GCperphenazine/amitriptyline tabs 50mg; 4mg 1 MO GCSYMBYAX CAPS 25MG; 12MG 5 QL (60 EA per 30 days)SYMBYAX CAPS 25MG; 3MG 4 QL (30 EA per 30 days)SYMBYAX CAPS 25MG; 6MG 4 QL (90 EA per 30 days)SYMBYAX CAPS 50MG; 12MG 5 QL (60 EA per 30 days)SYMBYAX CAPS 50MG; 6MG 4 QL (60 EA per 30 days)Monoamine Oxidase InhibitorsEMSAM PT24 12MG/24HR 5 QL (30 EA per 30 days)EMSAM PT24 6MG/24HR 4 QL (30 EA per 30 days)EMSAM PT24 9MG/24HR 4 QL (30 EA per 30 days)MARPLAN TABS 10MG 4phenelzine sulfate tabs 15mg 1 MO GCtranylcypromine sulfate tabs 10mg 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 20

Drug NameDrugTier Requirements/LimitsSerotonin/ Norepinephrine Reuptake Inhibitorscitalopram hydrobromide soln 10mg/5ml 1 MO GCcitalopram hydrobromide tabs 10mg 1 MO GCcitalopram hydrobromide tabs 20mg 1 MO GCcitalopram hydrobromide tabs 40mg 1 MO GCCYMBALTA CPEP 20MG 4 QL (60 EA per 30 days) STCYMBALTA CPEP 30MG 4 QL (60 EA per 30 days) STCYMBALTA CPEP 60MG 4 QL (30 EA per 30 days) STescitalopram oxalate soln 5mg/5ml 2 QL (600 ML per 30 days) MO GCescitalopram oxalate tabs 10mg 2 MO GCescitalopram oxalate tabs 20mg 2 QL (30 EA per 30 days) MO GCescitalopram oxalate tabs 5mg 2 QL (30 EA per 30 days) MO GCfluoxetine hcl caps 10mg 1 MO GCfluoxetine hcl caps 20mg 1 MO GCfluoxetine hcl caps 40mg 1 MO GCfluoxetine hcl soln 20mg/5ml 1 MO GCfluoxetine hcl tabs 10mg 1 MO GCfluoxetine hcl tabs 20mg 1 MO GCfluvoxamine maleate tabs 100mg 1 MO GCfluvoxamine maleate tabs 25mg 1 MO GCfluvoxamine maleate tabs 50mg 1 MO GCparoxetine hcl er tb24 12.5mg 2 MO GCparoxetine hcl er tb24 25mg 2 MO GCparoxetine hcl er tb24 37.5mg 2 MO GCparoxetine hcl tabs 10mg 1 MO GCparoxetine hcl tabs 20mg 1 MO GCparoxetine hcl tabs 30mg 1 MO GCparoxetine hcl tabs 40mg 1 MO GCPAXIL SUSP 10MG/5ML 4 STPEXEVA TABS 20MG 4 QL (30 EA per 30 days) STPEXEVA TABS 40MG 4 QL (30 EA per 30 days) STPRISTIQ TB24 100MG 4 QL (30 EA per 30 days) STPRISTIQ TB24 50MG 4 QL (30 EA per 30 days) STsertraline hcl conc 20mg/ml 1 MO GCsertraline hcl tabs 100mg 1 MO GCsertraline hcl tabs 25mg 1 MO GCsertraline hcl tabs 50mg 1 MO GCVENLAFAXINE HCL ER TB24 150MG 4 STVENLAFAXINE HCL ER TB24 225MG 4 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 21

Drug NameDrugTier Requirements/LimitsVENLAFAXINE HCL ER TB24 37.5MG 4 STVENLAFAXINE HCL ER TB24 75MG 4 STvenlafaxine hcl tabs 100mg 1 MO GCvenlafaxine hcl tabs 25mg 1 MO GCvenlafaxine hcl tabs 37.5mg 1 MO GCvenlafaxine hcl tabs 50mg 1 MO GCvenlafaxine hcl tabs 75mg 1 MO GCSerotonin/Norepinephrine Reuptake InhibitorsOLANZAPINE/FLUOXETINE CAPS 25MG; 12MG 5 QL (60 EA per 30 days)olanzapine/fluoxetine caps 25mg; 3mg 2 QL (30 EA per 30 days)olanzapine/fluoxetine caps 25mg; 6mg 2 QL (90 EA per 30 days)OLANZAPINE/FLUOXETINE CAPS 50MG; 12MG 5 QL (60 EA per 30 days)olanzapine/fluoxetine caps 50mg; 6mg 2 QL (60 EA per 30 days)Tricyclicsamitriptyline hcl tabs 100mg 1 MO GCamitriptyline hcl tabs 10mg 1 MO GCamitriptyline hcl tabs 150mg 1 MO GCamitriptyline hcl tabs 25mg 1 MO GCamitriptyline hcl tabs 50mg 1 MO GCamitriptyline hcl tabs 75mg 1 MO GCamoxapine tabs 100mg 1 MO GCamoxapine tabs 25mg 1 MO GCamoxapine tabs 50mg 1 MO GCclomipramine hcl caps 25mg 1 MO GCclomipramine hcl caps 50mg 1 MO GCclomipramine hcl caps 75mg 1 MO GCdesipramine hcl tabs 100mg 2 MO GCdesipramine hcl tabs 10mg 2 MO GCdesipramine hcl tabs 150mg 2 MO GCdesipramine hcl tabs 25mg 2 MO GCdesipramine hcl tabs 50mg 2 MO GCdesipramine hcl tabs 75mg 2 MO GCdoxepin hcl caps 100mg 1 MO GCdoxepin hcl caps 10mg 1 MO GCdoxepin hcl caps 150mg 1 MO GCdoxepin hcl caps 25mg 1 MO GCdoxepin hcl caps 50mg 1 MO GCdoxepin hcl caps 75mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 22

Drug NameDrugTier Requirements/Limitsdoxepin hcl conc 10mg/ml 1 MO GCimipramine hcl tabs 10mg 1 MO GCimipramine hcl tabs 25mg 1 MO GCimipramine hcl tabs 50mg 1 MO GCimipramine pamoate caps 100mg 2 MO GCIMIPRAMINE PAMOATE CAPS 125MG 4 QL (30 EA per 30 days)imipramine pamoate caps 150mg 2 MO GCimipramine pamoate caps 75mg 2 MO GCnortriptyline hcl caps 10mg 1 MO GCnortriptyline hcl caps 25mg 1 MO GCnortriptyline hcl caps 50mg 1 MO GCnortriptyline hcl caps 75mg 1 MO GCprotriptyline hcl tabs 10mg 2 MO GCprotriptyline hcl tabs 5mg 2 MO GCSILENOR TABS 3MG 4SILENOR TABS 6MG 4trimipramine maleate caps 100mg 2 MO GCtrimipramine maleate caps 25mg 2 MO GCtrimipramine maleate caps 50mg 2 MO GCAntiemeticsAntiemetics, Otherchlorpromazine hcl inj 25mg/ml 1 MO GCchlorpromazine hcl tabs 100mg 1 MO GCchlorpromazine hcl tabs 10mg 1 MO GCchlorpromazine hcl tabs 200mg 1 MO GCchlorpromazine hcl tabs 25mg 1 MO GCchlorpromazine hcl tabs 50mg 1 MO GCcompro supp 25mg 1 MO GCdiphenhydramine hcl caps 50mg 1 PA MO GChydroxyzine hcl inj 25mg/ml 1 PA MO GChydroxyzine hcl inj 50mg/ml 1 PA MO GChydroxyzine hcl soln 10mg/5ml 1 PA MO GChydroxyzine hcl tabs 10mg 1 PA MO GChydroxyzine hcl tabs 25mg 1 PA MO GChydroxyzine hcl tabs 50mg 1 PA MO GChydroxyzine pamoate caps 100mg 1 PA MO GChydroxyzine pamoate caps 25mg 1 PA MO GChydroxyzine pamoate caps 50mg 1 PA MO GCmeclizine hcl tabs 12.5mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 23

Drug NameDrugTier Requirements/Limitsmeclizine hcl tabs 25mg 1 MO GCmetoclopramide hcl inj 5mg/ml 1 MO GCmetoclopramide hcl soln 5mg/5ml 1 MO GCmetoclopramide hcl tabs 10mg 1 MO GCmetoclopramide hcl tabs 5mg 1 MO GCperphenazine tabs 16mg 1 MO GCperphenazine tabs 2mg 1 MO GCperphenazine tabs 4mg 1 MO GCperphenazine tabs 8mg 1 MO GCphenadoz supp 12.5mg 1 PA MO GCphenadoz supp 25mg 1 PA MO GCprochlorperazine edisylate inj 5mg/ml 1 MO GCprochlorperazine maleate tabs 10mg 1 MO GCprochlorperazine maleate tabs 5mg 1 MO GCpromethazine hcl inj 25mg/ml 1 PA MO GCpromethazine hcl inj 50mg/ml 1 PA MO GCpromethazine hcl supp 12.5mg 1 PA MO GCpromethazine hcl supp 25mg 1 PA MO GCpromethazine hcl syrp 6.25mg/5ml 1 PA MO GCpromethazine hcl tabs 12.5mg 1 PA MO GCpromethazine hcl tabs 25mg 1 PA MO GCpromethazine hcl tabs 50mg 1 PA MO GCpromethegan supp 25mg 1 PA MO GCpromethegan supp 50mg 1 PA MO GCTRANSDERM-SCOP PT72 1.5MG 4trimethobenzamide hcl caps 300mg 1 PA MO GCEmetogenic Therapy AdjunctsALOXI INJ 0.25MG/5ML 4DRONABINOL CAPS 10MG 5 QL (60 EA per 30 days) B/Ddronabinol caps 2.5mg 2 QL (60 EA per 30 days) B/D MOGCdronabinol caps 5mg 2 QL (60 EA per 30 days) B/D MOGCEMEND CAPS 0 4 QL (3 EA per 1 days) B/DEMEND CAPS 125MG 4 QL (1 EA per 1 days) B/DEMEND CAPS 40MG 4 QL (1 EA per 1 days) B/DEMEND CAPS 80MG 4 QL (2 EA per 1 days) B/DPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 24

Drug NameDrugTier Requirements/Limitsgranisetron hcl inj 1mg/ml 2 QL (14 ML per 30 days) B/D MOGCgranisetron hcl tabs 1mg 2 QL (60 EA per 30 days) B/D MOGCondansetron hcl soln 4mg/5ml 2 QL (450 ML per 30 days) B/D MOGCondansetron hcl tabs 24mg 2 B/D MO GCondansetron hcl tabs 4mg 2 QL (9 EA per 3 days) B/D MOGCondansetron hcl tabs 8mg 2 QL (9 EA per 3 days) B/D MOGCondansetron odt tbdp 4mg 2 QL (9 EA per 3 days) B/D MOGCondansetron odt tbdp 8mg 2 QL (45 EA per 30 days) B/D MOGCSANCUSO PTCH 3.1MG/24HR 5 QL (4 EA per 28 days) B/DAntifungalsAntifungalsABELCET INJ 5MG/ML 4 B/DAMBISOME INJ 50MG 4 B/DAMPHOTEC INJ 50MG 4 B/Damphotericin b inj 50mg 2 B/D MO GCANCOBON CAPS 250MG 4ANCOBON CAPS 500MG 4CANCIDAS INJ 70MG 5 PAciclopirox nail lacquer soln 8% 1 PA MO GCciclopirox olamine crea 0.77% 1 MO GCciclopirox gel 0.77% 1 MO GCciclopirox sham 1% 1 MO GCciclopirox susp 0.77% 1 MO GCclotrimazole soln 1% 1 MO GCclotrimazole troc 10mg 1 MO GCeconazole nitrate crea 1% 1 MO GCERTACZO CREA 2% 4EXELDERM CREA 1% 4EXELDERM SOLN 1% 4fluconazole in dextrose inj 56mg/ml; 400mg/200ml 1 MO GCfluconazole susr 10mg/ml 1 MO GCfluconazole susr 40mg/ml 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 25

Drug NameDrugTier Requirements/Limitsfluconazole tabs 100mg 1 MO GCfluconazole tabs 150mg 1 MO GCfluconazole tabs 200mg 1 MO GCfluconazole tabs 50mg 1 MO GCflucytosine caps 250mg 2 MO GCflucytosine caps 500mg 2 MO GCGRIS-PEG TABS 125MG 4GRIS-PEG TABS 250MG 4griseofulvin microsize susp 125mg/5ml 2 MO GCgriseofulvin microsize tabs 500mg 2griseofulvin ultramicrosize tabs 125mg 2griseofulvin ultramicrosize tabs 250mg 2itraconazole caps 100mg 2 QL (120 EA per 30 days) PA MOGCketoconazole crea 2% 1 MO GCketoconazole foam 2% 2 MO GCketoconazole sham 2% 1 MO GCketoconazole tabs 200mg 1 MO GCMENTAX CREA 1% 4miconazole 3 supp 200mg 1 MO GCMYCAMINE INJ 100MG 5MYCAMINE INJ 50MG 5NAFTIN CREA 1% 4NAFTIN GEL 1% 4NATACYN SUSP 5% 4NOXAFIL SUSP 40MG/ML 5 PAnystatin crea 100000unit/gm 1 MO GCnystatin oint 100000unit/gm 1 MO GCnystatin susp 100000unit/ml 1 MO GCnystatin tabs 500000unit 1 MO GCnystop powd 100000unit/gm 1 MO GCOXISTAT CREA 1% 4OXISTAT LOTN 1% 4pedi-dri powd 100000unit/gm 1 MO GCSPORANOX SOLN 10MG/ML 5 PAterbinafine hcl tabs 250mg 1 QL (30 EA per 30 days) PA MOGCterconazole crea 0.4% 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 26

Drug NameDrugTier Requirements/Limitsterconazole crea 0.8% 1terconazole supp 80mg 1 MO GCVFEND IV INJ 200MG 4 PAvoriconazole inj 200mg 2 PAVORICONAZOLE TABS 200MG 5 QL (60 EA per 30 days) PAVORICONAZOLE TABS 50MG 5 QL (120 EA per 30 days) PAzazole crea 0.4% 1 MO GCzazole crea 0.8% 1 MO GCZOLINZA CAPS 100MG 5 QL (120 EA per 30 days) PAAntigout AgentsAntigout Agentsallopurinol tabs 100mg 1 MO GCallopurinol tabs 300mg 1 MO GCCOLCRYS TABS 0.6MG 4 QL (120 EA per 30 days)probenecid/colchicine tabs 0.5mg; 500mg 1 MO GCprobenecid tabs 500mg 1 MO GCULORIC TABS 40MG 4 PAULORIC TABS 80MG 4 PAAntimigraine AgentsErgot Alkaloidsdihydroergotamine mesylate inj 1mg/ml 2 MO GCMIGERGOT SUPP 100MG; 2MG 4MIGRANAL SOLN 4MG/ML 5 QL (12 ML per 30 days)ProphylacticBOTOX INJ 100UNIT 4 PAtimolol maleate tabs 10mg 1 MO GCtimolol maleate tabs 20mg 1 MO GCtimolol maleate tabs 5mg 1 MO GCSerotonin (5-HT) 1b/1d Receptor AgonistsAXERT TABS 12.5MG 4 QL (24 EA per 28 days)FROVA TABS 2.5MG 4 QL (12 EA per 30 days)IMITREX SOLN 20MG/ACT 4IMITREX SOLN 5MG/ACT 4MAXALT-MLT TBDP 10MG 4 QL (12 EA per 30 days)MAXALT-MLT TBDP 5MG 4 QL (12 EA per 30 days)MAXALT TABS 10MG 4 QL (12 EA per 30 days)MAXALT TABS 5MG 4 QL (12 EA per 30 days)naratriptan hcl tabs 1mg 1 MO GCnaratriptan hcl tabs 2.5mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 27

Drug NameDrugTier Requirements/LimitsRELPAX TABS 20MG 4 QL (9 EA per 30 days)RELPAX TABS 40MG 4 QL (9 EA per 30 days)rizatriptan benzoate tbdp 10mg 2 QL (12 EA per 30 days)rizatriptan benzoate tbdp 5mg 2 QL (12 EA per 30 days)sumatriptan succinate inj 6mg/0.5ml 2 MO GCsumatriptan succinate tabs 100mg 1 MO GCsumatriptan succinate tabs 25mg 1 MO GCsumatriptan succinate tabs 50mg 1 MO GCZOMIG TABS 2.5MG 4 QL (9 EA per 30 days)ZOMIG TABS 5MG 4 QL (9 EA per 30 days)Antimyasthenic AgentsParasympathomimeticsMESTINON TIMESPAN TBCR 180MG 4MESTINON SYRP 60MG/5ML 4pyridostigmine bromide tabs 60mg 1 MO GCAntimycobacterialsAntimycobacterials, OtherACZONE GEL 5% 4 PADAPSONE TABS 100MG 3 MODAPSONE TABS 25MG 3 MOMYCOBUTIN CAPS 150MG 4Antitubercularsethambutol hcl tabs 100mg 1 MO GCethambutol hcl tabs 400mg 1 MO GCisoniazid tabs 100mg 1 MO GCisoniazid tabs 300mg 1 MO GCrifampin caps 150mg 1 MO GCrifampin caps 300mg 1 MO GCrifampin inj 600mg 1 MO GCRIFATER TABS 50MG; 300MG; 120MG 4AntineoplasticsAlkylating AgentsCEENU CAPS 100MG 4CEENU CAPS 10MG 4CEENU CAPS 40MG 4cyclophosphamide tabs 25mg 2 B/D MO GCcyclophosphamide tabs 50mg 2 B/D MO GCHEXALEN CAPS 50MG 5 PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 28

Drug NameDrugTier Requirements/LimitsLEUKERAN TABS 2MG 4MATULANE CAPS 50MG 5Antiangiogenic AgentsREVLIMID CAPS 10MG 5 QL (30 EA per 30 days) PA LAREVLIMID CAPS 15MG 5 QL (21 EA per 28 days) PA LAREVLIMID CAPS 25MG 5 QL (21 EA per 28 days) PA LAREVLIMID CAPS 5MG 5 QL (30 EA per 30 days) PA LATHALOMID CAPS 100MG 5 QL (30 EA per 30 days) PATHALOMID CAPS 150MG 5 QL (60 EA per 30 days) PATHALOMID CAPS 200MG 5 QL (60 EA per 30 days) PATHALOMID CAPS 50MG 5 QL (30 EA per 30 days) PAAntiestrogens/ModifiersEMCYT CAPS 140MG 4 PAFARESTON TABS 60MG 4tamoxifen citrate tabs 10mg 1 MO GCtamoxifen citrate tabs 20mg 1 MO GCAntimetabolitesDROXIA CAPS 300MG 4GEMCITABINE HCL INJ 1GM 5hydroxyurea caps 500mg 1 MO GCTABLOID TABS 40MG 4Antineoplastics, Otheramifostine inj 500mg 1 MO GCleucovorin calcium inj 100mg 1 MO GCleucovorin calcium inj 350mg 1 MO GCleucovorin calcium tabs 10mg 1 MO GCleucovorin calcium tabs 15mg 1 MO GCleucovorin calcium tabs 25mg 1 MO GCleucovorin calcium tabs 5mg 1 MO GCLIPODOX 50 INJ 2MG/ML 5LIPODOX INJ 2MG/ML 5mitoxantrone hcl inj 2mg/ml 1 MO GCYERVOY INJ 50MG/10ML 5 PAZELBORAF TABS 240MG 5 QL (240 EA per 30 days) PAAntineoplasticsadriamycin inj 2mg/ml 2 MO GCALIMTA INJ 500MG 5ARRANON INJ 5MG/ML 5AVASTIN INJ 100MG/4ML 5 PAPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 29

Drug NameDrugTier Requirements/LimitsCAMPATH INJ 30MG/ML 5carboplatin inj 150mg/15ml 2 MO GCCYTARABINE AQUEOUS INJ 100MG/ML 4DACOGEN INJ 50MG 5dexrazoxane inj 500mg 5DOCETAXEL INJ 80MG/8ML 5DOXIL INJ 2MG/ML 5ELOXATIN INJ 100MG/20ML 5ERBITUX INJ 100MG/50ML 5 PAERIVEDGE CAPS 150MG 5 PAFASLODEX INJ 250MG/5ML 4HERCEPTIN INJ 440MG 5INLYTA TABS 1MG 5 PAINLYTA TABS 5MG 5 PAirinotecan inj 100mg/5ml 2 MO GCIXEMPRA KIT INJ 45MG 5 PAJEVTANA INJ 60MG/1.5ML 5 PAmesna inj 100mg/ml 2 MO GCMESNEX TABS 400MG 5mitomycin inj 20mg 2 MO GCMUSTARGEN INJ 10MG 4PACLITAXEL INJ 300MG/50ML 4PROLEUKIN INJ 22000000UNIT 5 PATAXOTERE INJ 80MG/4ML 5 PATREANDA INJ 100MG 5VECTIBIX INJ 100MG/5ML 5 PAVELCADE INJ 3.5MG 5VIDAZA INJ 100MG 5VINCASAR PFS INJ 1MG/ML 4Aromatase Inhibitors, 3rd Generationanastrozole tabs 1mg 1 MO GCexemestane tabs 25mg 2 MO GCletrozole tabs 2.5mg 1 MO GCEnzyme InhibitorsETOPOSIDE INJ 20MG/ML 3 MOJAKAFI TABS 10MG 3 QL (60 EA per 30 days) PA MOJAKAFI TABS 15MG 3 QL (60 EA per 30 days) PA MOJAKAFI TABS 20MG 3 QL (60 EA per 30 days) PA MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 30

Drug NameDrugTier Requirements/LimitsJAKAFI TABS 25MG 3 QL (60 EA per 30 days) PA MOJAKAFI TABS 5MG 3 QL (60 EA per 30 days) PA MOMolecular Target InhibitorsAFINITOR TABS 10MG 5 QL (60 EA per 30 days) PAAFINITOR TABS 5MG 5 QL (90 EA per 30 days) PAAFINITOR TABS 7.5MG 5 QL (30 EA per 30 days) PABOSULIF TABS 100MG 5 PABOSULIF TABS 500MG 5 PACAPRELSA TABS 100MG 5 QL (60 EA per 30 days) PA LACAPRELSA TABS 300MG 5 QL (90 EA per 90 days) PA LAGLEEVEC TABS 100MG 5 QL (90 EA per 30 days) PAGLEEVEC TABS 400MG 5 QL (60 EA per 30 days) PANEXAVAR TABS 200MG 5 QL (120 EA per 30 days) PA LASPRYCEL TABS 100MG 5 QL (60 EA per 30 days) PASPRYCEL TABS 140MG 5 QL (30 EA per 30 days) PASPRYCEL TABS 20MG 5 QL (150 EA per 30 days) PASPRYCEL TABS 50MG 5 QL (60 EA per 30 days) PASPRYCEL TABS 70MG 5 QL (60 EA per 30 days) PASPRYCEL TABS 80MG 5 QL (30 EA per 30 days) PASTIVARGA TABS 40MG 5 PASUTENT CAPS 12.5MG 5 QL (90 EA per 30 days) PASUTENT CAPS 25MG 5 QL (30 EA per 30 days) PASUTENT CAPS 50MG 5 QL (30 EA per 30 days) PATARCEVA TABS 100MG 5 QL (90 EA per 90 days) PATARCEVA TABS 150MG 5 QL (90 EA per 90 days) PATARCEVA TABS 25MG 5 QL (60 EA per 30 days) PATASIGNA CAPS 150MG 5 QL (120 EA per 30 days) PATASIGNA CAPS 200MG 5 QL (120 EA per 30 days) PATYKERB TABS 250MG 5 QL (540 EA per 90 days) PA LAVOTRIENT TABS 200MG 5 QL (360 EA per 90 days) PAXALKORI CAPS 200MG 5 QL (60 EA per 30 days) PAXALKORI CAPS 250MG 5 QL (60 EA per 30 days) PAMonoclonal AntibodiesARZERRA INJ 100MG/5ML 5 PARITUXAN INJ 10MG/ML 5 PARetinoidsPANRETIN GEL 0.1% 5 PATARGRETIN CAPS 75MG 5 PATARGRETIN GEL 1% 5 PAPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 31

Drug NameDrugTier Requirements/LimitsTRETINOIN CAPS 10MG 3 MOtretinoin crea 0.025% 2 PA MO GCtretinoin crea 0.05% 2 PA MO GCtretinoin crea 0.1% 2 PA MO GCtretinoin gel 0.01% 2 PA MO GCtretinoin gel 0.025% 2 PA MO GCAntiparasiticsAnthelminticsALBENZA TABS 200MG 3 MOBILTRICIDE TABS 600MG 3 MOSTROMECTOL TABS 3MG 3 MOAntiprotozoalsALINIA TABS 500MG 4atovaquone/proguanil hcl tabs 250mg; 100mg 2 MO GCchloroquine phosphate tabs 250mg 1 MO GCchloroquine phosphate tabs 500mg 1 MO GCDARAPRIM TABS 25MG 4hydroxychloroquine sulfate tabs 200mg 1 MO GCmefloquine hcl tabs 250mg 2 MO GCMEPRON SUSP 750MG/5ML 5NEBUPENT SOLR 300MG 4 B/DQUALAQUIN CAPS 324MG 4 QL (42 EA per 30 days)tinidazole tabs 250mg 2tinidazole tabs 500mg 2Pediculicides/ ScabicidesEURAX CREA 10% 4EURAX LOTN 10% 4lindane lotn 1% 2 MO GCLINDANE SHAM 1% 4malathion lotn 0.5% 2 MO GCpermethrin crea 5% 1 MO GCPediculicides/ScabicidesSKLICE LOTN 0.5% 4Antiparkinson AgentsAnticholinergicsbenztropine mesylate inj 1mg/ml 1 MO GCbenztropine mesylate tabs 0.5mg 1 MO GCbenztropine mesylate tabs 1mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 32

Drug NameDrugTier Requirements/Limitsbenztropine mesylate tabs 2mg 1 MO GCtrihexyphenidyl hcl tabs 2mg 1 MO GCtrihexyphenidyl hcl tabs 5mg 1 MO GCAntiparkinson Agents, Otheramantadine hcl caps 100mg 1 MO GCamantadine hcl syrp 50mg/5ml 1 MO GCamantadine hcl tabs 100mg 1 MO GCCOMTAN TABS 200MG 4 QL (240 EA per 30 days)entacapone tabs 200mg 2 QL (240 EA per 30 days)TASMAR TABS 100MG 5 QL (90 EA per 30 days)Antiparkinson AgentsSTALEVO 100 TABS 25MG; 200MG; 100MG 4 QL (240 EA per 30 days)STALEVO 125 TABS 31.25MG; 200MG; 125MG 4 QL (240 EA per 30 days)STALEVO 150 TABS 37.5MG; 200MG; 150MG 4 QL (240 EA per 30 days)STALEVO 200 TABS 50MG; 200MG; 200MG 4 QL (240 EA per 30 days)STALEVO 50 TABS 12.5MG; 200MG; 50MG 4 QL (240 EA per 30 days)STALEVO 75 TABS 18.75MG; 200MG; 75MG 4 QL (240 EA per 30 days)Dopamine AgonistsAPOKYN INJ 10MG/ML 5 QL (60 ML per 30 days) PA LAbromocriptine mesylate caps 5mg 2 MO GCbromocriptine mesylate tabs 2.5mg 2 MO GCpramipexole dihydrochloride tabs 0.125mg 1 MO GCpramipexole dihydrochloride tabs 0.25mg 1 MO GCpramipexole dihydrochloride tabs 0.5mg 1 MO GCpramipexole dihydrochloride tabs 0.75mg 1 MO GCpramipexole dihydrochloride tabs 1.5mg 1 MO GCpramipexole dihydrochloride tabs 1mg 1 MO GCropinirole er tb24 12mg 2 MO GCropinirole er tb24 2mg 2 MO GCropinirole er tb24 4mg 2 MO GCropinirole er tb24 6mg 2 MO GCropinirole er tb24 8mg 2 MO GCropinirole hcl tabs 0.25mg 1 MO GCropinirole hcl tabs 0.5mg 1 MO GCropinirole hcl tabs 1mg 1 MO GCropinirole hcl tabs 2mg 1 MO GCropinirole hcl tabs 3mg 1 MO GCropinirole hcl tabs 4mg 1 MO GCropinirole hcl tabs 5mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 33

Drug NameDrugTierDopamine Precursors/ L-Amino Acid DecarboxylaseInhibitorscarbidopa/levodopa er tbcr 25mg; 100mg 1 MO GCcarbidopa/levodopa er tbcr 50mg; 200mg 1 MO GCcarbidopa/levodopa tabs 10mg; 100mg 1 MO GCcarbidopa/levodopa tabs 25mg; 100mg 1 MO GCcarbidopa/levodopa tabs 25mg; 250mg 1 MO GCLODOSYN TABS 25MG 4Dopamine Precursors/L- Amino Acid DecarboxylaseInhibitorscarbidopa/levodopa/entacapone tabs 12.5mg; 200mg;50mgRequirements/Limits2 QL (240 EA per 30 days)carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 2 QL (240 EA per 30 days)50mgcarbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 2 QL (240 EA per 30 days)75mgcarbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 2 QL (240 EA per 30 days)75mgcarbidopa/levodopa/entacapone tabs 25mg; 200mg; 2 QL (240 EA per 30 days)100mgcarbidopa/levodopa/entacapone tabs 25mg; 200mg; 2 QL (240 EA per 30 days)100mgcarbidopa/levodopa/entacapone tabs 31.25mg; 200mg; 2 QL (240 EA per 30 days)125mgcarbidopa/levodopa/entacapone tabs 31.25mg; 200mg; 2 QL (240 EA per 30 days)125mgcarbidopa/levodopa/entacapone tabs 37.5mg; 200mg; 2 QL (240 EA per 30 days)150mgcarbidopa/levodopa/entacapone tabs 37.5mg; 200mg; 2 QL (240 EA per 30 days)150mgcarbidopa/levodopa/entacapone tabs 50mg; 200mg; 2 QL (240 EA per 30 days)200mgcarbidopa/levodopa/entacapone tabs 50mg; 200mg; 2 QL (240 EA per 30 days)200mgMonoamine Oxidase B (MAO-B) InhibitorsAZILECT TABS 0.5MG 4 QL (30 EA per 30 days)AZILECT TABS 1MG 4 QL (30 EA per 30 days)selegiline hcl caps 5mg 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 34

Drug NameDrugTier Requirements/Limitsselegiline hcl tabs 5mg 2 MO GCZELAPAR TBDP 1.25MG 4Antipsychotics1st Generation/ Typicalfluphenazine decanoate inj 25mg/ml 1 MO GCfluphenazine hcl elix 2.5mg/5ml 1 MO GCfluphenazine hcl inj 2.5mg/ml 1 MO GCfluphenazine hcl tabs 10mg 1 MO GCfluphenazine hcl tabs 1mg 1 MO GCfluphenazine hcl tabs 2.5mg 1 MO GCfluphenazine hcl tabs 5mg 1 MO GChaloperidol decanoate inj 100mg/ml 1 MO GChaloperidol decanoate inj 50mg/ml 1 MO GChaloperidol lactate inj 5mg/ml 1 MO GChaloperidol conc 2mg/ml 1 MO GChaloperidol tabs 0.5mg 1 MO GChaloperidol tabs 10mg 1 MO GChaloperidol tabs 1mg 1 MO GChaloperidol tabs 20mg 1 MO GChaloperidol tabs 2mg 1 MO GChaloperidol tabs 5mg 1 MO GCloxapine succinate caps 10mg 2 MO GCloxapine succinate caps 25mg 2 MO GCloxapine succinate caps 50mg 2 MO GCloxapine succinate caps 5mg 2 MO GCORAP TABS 1MG 3 MOORAP TABS 2MG 3 MOthioridazine hcl tabs 100mg 1 PA MO GCthioridazine hcl tabs 10mg 1 PA MO GCthioridazine hcl tabs 25mg 1 PA MO GCthioridazine hcl tabs 50mg 1 PA MO GCthiothixene caps 10mg 1 MO GCthiothixene caps 1mg 1 MO GCthiothixene caps 2mg 1 MO GCthiothixene caps 5mg 1 MO GCtrifluoperazine hcl tabs 10mg 1 MO GCtrifluoperazine hcl tabs 1mg 1 MO GCtrifluoperazine hcl tabs 2mg 1 MO GCtrifluoperazine hcl tabs 5mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 35

Drug NameDrugTier Requirements/Limits2nd Generation/ AtypicalABILIFY DISCMELT TBDP 10MG 4 QL (60 EA per 30 days)ABILIFY DISCMELT TBDP 15MG 5 QL (60 EA per 30 days)ABILIFY INJ 9.75MG/1.3ML 4ABILIFY SOLN 1MG/ML 4 QL (900 ML per 30 days) STABILIFY TABS 10MG 4 QL (30 EA per 30 days) STABILIFY TABS 15MG 4 QL (30 EA per 30 days) STABILIFY TABS 20MG 5 QL (30 EA per 30 days) STABILIFY TABS 2MG 4 QL (30 EA per 30 days) STABILIFY TABS 30MG 5 QL (30 EA per 30 days) STABILIFY TABS 5MG 4 QL (30 EA per 30 days) STFANAPT TABS 10MG 4 QL (60 EA per 30 days) STFANAPT TABS 12MG 4 QL (60 EA per 30 days) STFANAPT TABS 1MG 4 QL (30 EA per 30 days) STFANAPT TABS 2MG 4 QL (30 EA per 30 days) STFANAPT TABS 4MG 4 QL (30 EA per 30 days) STFANAPT TABS 6MG 4 QL (60 EA per 30 days) STFANAPT TABS 8MG 4 QL (60 EA per 30 days) STGEODON INJ 20MG 4 QL (300 EA per 30 days)INVEGA SUSTENNA INJ 117MG/0.75ML 5 QL (1 ML per 28 days)INVEGA SUSTENNA INJ 156MG/ML 5 QL (1 ML per 28 days)INVEGA SUSTENNA INJ 234MG/1.5ML 5 QL (1 ML per 28 days)INVEGA SUSTENNA INJ 39MG/0.25ML 4 QL (1 ML per 28 days)INVEGA SUSTENNA INJ 78MG/0.5ML 4 QL (1 ML per 28 days)INVEGA TB24 1.5MG 4 QL (30 EA per 30 days) STINVEGA TB24 3MG 4 QL (30 EA per 30 days) STINVEGA TB24 6MG 4 QL (60 EA per 30 days) STINVEGA TB24 9MG 5 QL (30 EA per 30 days) STLATUDA TABS 20MG 4 QL (30 EA per 30 days) STLATUDA TABS 40MG 4 QL (90 EA per 30 days) STLATUDA TABS 80MG 4 QL (30 EA per 30 days) STolanzapine odt tbdp 10mg 2 MO GColanzapine odt tbdp 15mg 2 MO GColanzapine odt tbdp 20mg 2 MO GColanzapine odt tbdp 5mg 2 MO GColanzapine inj 10mg 2 MO GColanzapine tabs 10mg 2 MO GColanzapine tabs 15mg 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 36

Drug NameDrugTier Requirements/Limitsolanzapine tabs 2.5mg 2 MO GColanzapine tabs 20mg 2 MO GColanzapine tabs 5mg 2 MO GColanzapine tabs 7.5mg 2 MO GCquetiapine fumarate tabs 100mg 2 MO GCquetiapine fumarate tabs 200mg 2 MO GCquetiapine fumarate tabs 25mg 2 MO GCquetiapine fumarate tabs 300mg 2 MO GCquetiapine fumarate tabs 400mg 2 MO GCquetiapine fumarate tabs 50mg 2 MO GCRISPERDAL CONSTA INJ 12.5MG 4 QL (2 EA per 28 days)RISPERDAL CONSTA INJ 25MG 4 QL (2 EA per 28 days)RISPERDAL CONSTA INJ 37.5MG 5 QL (1 EA per 28 days)RISPERDAL CONSTA INJ 50MG 5 QL (2 EA per 28 days)risperidone odt tbdp 0.25mg 1 MO GCrisperidone odt tbdp 0.5mg 1 MO GCrisperidone odt tbdp 1mg 1 MO GCrisperidone odt tbdp 2mg 1 MO GCrisperidone odt tbdp 3mg 1 MO GCrisperidone odt tbdp 4mg 1 MO GCrisperidone soln 1mg/ml 1 MO GCrisperidone tabs 0.25mg 1 MO GCrisperidone tabs 0.5mg 1 MO GCrisperidone tabs 1mg 1 MO GCrisperidone tabs 2mg 1 MO GCrisperidone tabs 3mg 1 MO GCrisperidone tabs 4mg 1 MO GCSAPHRIS SUBL 10MG 4 QL (60 EA per 30 days)SAPHRIS SUBL 5MG 4 QL (60 EA per 30 days)ziprasidone hcl caps 20mg 2 QL (60 EA per 30 days) MO GCziprasidone hcl caps 40mg 2 QL (60 EA per 30 days) MO GCziprasidone hcl caps 60mg 2 QL (60 EA per 30 days) MO GCziprasidone hcl caps 80mg 2 QL (60 EA per 30 days) MO GCTreatment-Resistantclozapine odt tbdp 100mg 2clozapine odt tbdp 100mg 2clozapine odt tbdp 100mg 2clozapine odt tbdp 25mg 2clozapine odt tbdp 25mg 2PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 37

Drug NameDrugTier Requirements/Limitsclozapine odt tbdp 25mg 2clozapine tabs 100mg 2 MO GCclozapine tabs 200mg 2 MO GCclozapine tabs 25mg 2 MO GCclozapine tabs 50mg 2 MO GCFAZACLO TBDP 100MG 4FAZACLO TBDP 25MG 4Antispasticity AgentsAntispasticity Agentsbaclofen tabs 10mg 1 MO GCbaclofen tabs 20mg 1 MO GCdantrolene sodium caps 100mg 2 MO GCdantrolene sodium caps 25mg 2 MO GCdantrolene sodium caps 50mg 2 MO GCtizanidine hcl tabs 2mg 1 MO GCtizanidine hcl tabs 4mg 1 MO GCXEOMIN INJ 50UNIT 4 PAAntiviralsAnti-cytomegalovirus (CMV) Agentsfoscarnet sodium inj 24mg/ml 2 MO GCganciclovir inj 500mg 2 B/D MO GCVALCYTE TABS 450MG 5 QL (84 EA per 30 days)ZIRGAN GEL 0.15% 4Anti-HIV Agents, Non-nucleoside Reverse TranscriptaseInhibitorsEDURANT TABS 25MG 5INTELENCE TABS 100MG 5 QL (120 EA per 30 days)INTELENCE TABS 200MG 5 QL (60 EA per 30 days)nevirapine susp 50mg/5ml 2nevirapine tabs 200mg 2 MO GCRESCRIPTOR TABS 100MG 4RESCRIPTOR TABS 200MG 3 MOSTRIBILD TABS 150MG; 150MG; 200MG; 300MG 5 QL (30 EA per 30 days) MOSUSTIVA CAPS 200MG 4SUSTIVA CAPS 50MG 4SUSTIVA TABS 600MG 4VIRAMUNE XR TB24 400MG 4VIRAMUNE SUSP 50MG/5ML 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 38

Drug NameDrugTier Requirements/LimitsAnti-HIV Agents, Nucleoside and Nucleotide ReverseTranscriptase Inhibitorsabacavir tabs 300mg 2COMPLERA TABS 200MG; 25MG; 300MG 5didanosine cpdr 125mg 2 MO GCdidanosine cpdr 200mg 2 MO GCdidanosine cpdr 250mg 2 MO GCdidanosine cpdr 400mg 2 MO GCEMTRIVA CAPS 200MG 4EMTRIVA SOLN 10MG/ML 4EPIVIR SOLN 10MG/ML 4EPZICOM TABS 600MG; 300MG 5LAMIVUDINE/ZIDOVUDINE TABS 150MG; 300MG 5lamivudine tabs 150mg 2 MO GClamivudine tabs 300mg 2 MO GCRETROVIR IV INFUSION INJ 10MG/ML 4stavudine caps 15mg 2 MO GCstavudine caps 20mg 2 MO GCstavudine caps 30mg 2 MO GCstavudine caps 40mg 2 MO GCTRIZIVIR TABS 300MG; 150MG; 300MG 5TRUVADA TABS 200MG; 300MG 5VIDEX PEDIATRIC SOLR 2GM 4VIREAD POWD 40MG/GM 4VIREAD TABS 150MG 5VIREAD TABS 200MG 5VIREAD TABS 250MG 5VIREAD TABS 300MG 5ZERIT SOLR 1MG/ML 4ZIAGEN SOLN 20MG/ML 4ZIAGEN TABS 300MG 4zidovudine caps 100mg 1 MO GCzidovudine syrp 50mg/5ml 1 MO GCzidovudine tabs 300mg 1 MO GCAnti-HIV Agents, OtherFUZEON INJ 90MG 5 QL (60 EA per 30 days)ISENTRESS CHEW 100MG 3 MOISENTRESS CHEW 25MG 3 MOISENTRESS TABS 400MG 5 QL (60 EA per 30 days) MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 39

Drug NameDrugTier Requirements/LimitsSELZENTRY TABS 150MG 5 QL (60 EA per 30 days)SELZENTRY TABS 300MG 5 QL (120 EA per 30 days)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 250MG 5 QL (120 EA per 30 days)APTIVUS SOLN 100MG/ML 5CRIXIVAN CAPS 400MG 3 MOINVIRASE CAPS 200MG 4INVIRASE TABS 500MG 5KALETRA SOLN 400MG/5ML; 100MG/5ML 5KALETRA TABS 100MG; 25MG 4KALETRA TABS 200MG; 50MG 5LEXIVA SUSP 50MG/ML 4LEXIVA TABS 700MG 5NORVIR CAPS 100MG 4NORVIR SOLN 80MG/ML 4NORVIR TABS 100MG 4PREZISTA TABS 150MG 5PREZISTA TABS 400MG 5PREZISTA TABS 600MG 5PREZISTA TABS 75MG 4REYATAZ CAPS 100MG 4REYATAZ CAPS 150MG 5REYATAZ CAPS 200MG 5REYATAZ CAPS 300MG 5VIRACEPT TABS 250MG 5VIRACEPT TABS 625MG 5Anti-influenza AgentsRELENZA DISKHALER AEPB 5MG/BLISTER 4 QL (60 EA per 180 days)rimantadine hcl tabs 100mg 2 MO GCTAMIFLU CAPS 45MG 4 QL (28 EA per 180 days)TAMIFLU CAPS 75MG 4 QL (28 EA per 180 days)Antihepatitis AgentsBARACLUDE SOLN 0.05MG/ML 4 QL (600 ML per 30 days)BARACLUDE TABS 0.5MG 5 QL (60 EA per 30 days)BARACLUDE TABS 1MG 5 QL (30 EA per 30 days)EPIVIR HBV SOLN 5MG/ML 4EPIVIR HBV TABS 100MG 4HEPSERA TABS 10MG 5 QL (30 EA per 30 days)PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 40

Drug NameDrugTier Requirements/LimitsINCIVEK TABS 375MG 5 QL (504 EA per 84 days) PAINTRON-A W/DILUENT INJ 10MU 4 PAINTRON-A INJ 6000000UNIT/ML 4 PAPEG-INTRON REDIPEN INJ 120MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON REDIPEN INJ 150MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON REDIPEN INJ 50MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON REDIPEN INJ 80MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON INJ 50MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEGASYS PROCLICK INJ 135MCG/0.5ML 5 QL (4 ML per 28 days) PAPEGASYS INJ 180MCG/0.5ML 5 QL (2 EA per 28 days) PAPEGASYS INJ 180MCG/ML 5 QL (4 ML per 28 days) PARIBAPAK TABS 400MG 5 PAribasphere caps 200mg 2 PA MO GCRIBASPHERE TABS 200MG 4 PARIBASPHERE TABS 400MG 5 PARIBASPHERE TABS 600MG 5 PAribavirin caps 200mg 2 PA MO GCribavirin tabs 200mg 2 PA MO GCSYLATRON INJ 296MCG 5 QL (4 EA per 28 days) PASYLATRON INJ 444MCG 5 QL (4 EA per 28 days) PASYLATRON INJ 888MCG 5 QL (4 EA per 28 days) PATYZEKA TABS 600MG 5 QL (30 EA per 30 days)VICTRELIS CAPS 200MG 5 QL (360 EA per 30 days) PAVIRAZOLE SOLR 6GM 5 B/DAntiherpetic Agentsacyclovir sodium inj 500mg 1 MO GCacyclovir caps 200mg 1 MO GCacyclovir susp 200mg/5ml 1 MO GCacyclovir tabs 400mg 1 MO GCacyclovir tabs 800mg 1 MO GCDENAVIR CREA 1% 4 QL (5 GM per 30 days)famciclovir tabs 125mg 2 MO GCfamciclovir tabs 250mg 2 MO GCfamciclovir tabs 500mg 2 MO GCtrifluridine soln 1% 2 MO GCvalacyclovir hcl tabs 1000mg 2 MO GCvalacyclovir hcl tabs 500mg 2 MO GCZOVIRAX CREA 5% 4 QL (15 GM per 30 days)ZOVIRAX OINT 5% 4 QL (30 GM per 30 days)PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 41

Drug NameDrugTier Requirements/LimitsAntiviralsATRIPLA TABS 600MG; 200MG; 300MG 5AnxiolyticsAnxiolytics, Otheralprazolam er tb24 0.5mg 2 QL (120 EA per 30 days) MO GCalprazolam intensol conc 1mg/ml 2 QL (60 ML per 30 days) MO GCalprazolam odt tbdp 0.25mg 2 QL (120 EA per 30 days) MO GCalprazolam odt tbdp 0.5mg 2 QL (120 EA per 30 days) MO GCalprazolam odt tbdp 1mg 2 QL (60 EA per 30 days) MO GCalprazolam odt tbdp 2mg 2 QL (60 EA per 30 days) MO GCalprazolam xr tb24 1mg 2 QL (60 EA per 30 days) MO GCalprazolam xr tb24 2mg 2 QL (60 EA per 30 days) MO GCalprazolam xr tb24 3mg 2 QL (60 EA per 30 days) MO GCalprazolam tabs 0.25mg 2 QL (120 EA per 30 days) MO GCalprazolam tabs 0.5mg 2 QL (120 EA per 30 days) MO GCalprazolam tabs 1mg 2 QL (60 EA per 30 days) MO GCalprazolam tabs 2mg 2 QL (60 EA per 30 days) MO GCbuspirone hcl tabs 10mg 1 MO GCbuspirone hcl tabs 15mg 1 MO GCbuspirone hcl tabs 30mg 1 MO GCbuspirone hcl tabs 5mg 1 MO GCbuspirone hcl tabs 7.5mg 2 MO GCclonazepam odt tbdp 0.125mg 2 QL (90 EA per 30 days) PA MOGCclonazepam odt tbdp 0.25mg 2 QL (90 EA per 30 days) PA MOGCclonazepam odt tbdp 0.5mg 2 QL (90 EA per 30 days) PA MOGCclonazepam odt tbdp 1mg 2 QL (90 EA per 30 days) PA MOGCclonazepam odt tbdp 2mg 2 QL (300 EA per 30 days) PA MOGCclonazepam tabs 0.5mg 1 QL (90 EA per 30 days) PA MOGCclonazepam tabs 1mg 1 QL (90 EA per 30 days) PA MOGCclonazepam tabs 2mg 1 QL (300 EA per 30 days) PA MOGCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 42

Drug NameDrugTier Requirements/Limitsclorazepate dipotassium tabs 15mg 2 QL (90 EA per 30 days) PA MOGCclorazepate dipotassium tabs 3.75mg 2 QL (90 EA per 30 days) PA MOGCclorazepate dipotassium tabs 7.5mg 2 QL (90 EA per 30 days) PA MOGCDIAZEPAM GEL 10MG 4 PAdiazepam soln 1mg/ml 1 QL (1200 ML per 30 days) PAMO GCdiazepam tabs 10mg 1 QL (120 EA per 30 days) PA MOGCdiazepam tabs 2mg 1 QL (60 EA per 30 days) PA MOGCdiazepam tabs 5mg 1 QL (60 EA per 30 days) PA MOGClorazepam intensol conc 2mg/ml 2 QL (45 ML per 30 days) MO GClorazepam tabs 0.5mg 2 QL (180 EA per 30 days) MO GClorazepam tabs 1mg 2 QL (90 EA per 30 days) MO GClorazepam tabs 2mg 2 QL (30 EA per 30 days) MO GCmeprobamate tabs 200mg 2 PA MO GCmeprobamate tabs 400mg 2 PA MO GCtemazepam caps 15mg 2 QL (30 EA per 30 days) MO GCtemazepam caps 30mg 2 QL (30 EA per 30 days) MO GCSSRIs/ SNRIsvenlafaxine hcl er cp24 150mg 1 MO GCvenlafaxine hcl er cp24 37.5mg 1 MO GCvenlafaxine hcl er cp24 75mg 1 MO GCBipolar AgentsMood Stabilizerscarbamazepine er cp12 100mg 2 MO GCcarbamazepine er cp12 200mg 2 MO GCcarbamazepine er cp12 300mg 2 MO GClithium carbonate er tbcr 300mg 1 MO GClithium carbonate er tbcr 450mg 1 MO GClithium carbonate caps 150mg 1 MO GClithium carbonate caps 300mg 1 MO GClithium carbonate caps 600mg 1 MO GClithium carbonate tabs 300mg 1 MO GClithium citrate soln 8meq/5ml 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 43

Drug NameDrugTier Requirements/LimitsBlood Glucose RegulatorsAntidiabetic Agentsacarbose tabs 100mg 1 QL (90 EA per 30 days) MO GCacarbose tabs 25mg 1 QL (90 EA per 30 days) MO GCacarbose tabs 50mg 1 QL (90 EA per 30 days) MO GCACTOPLUS MET XR TB24 1000MG; 15MG 4 MO GCACTOPLUS MET XR TB24 1000MG; 30MG 4 MO GCACTOPLUS MET TABS 500MG; 15MG 4 MO GCACTOPLUS MET TABS 850MG; 15MG 4 MO GCACTOS TABS 15MG 4 QL (30 EA per 30 days) GCACTOS TABS 30MG 4 QL (30 EA per 30 days) GCACTOS TABS 45MG 4 QL (30 EA per 30 days) GCAVANDAMET TABS 1000MG; 2MG 4 MO GCAVANDAMET TABS 1000MG; 4MG 4 MO GCAVANDAMET TABS 500MG; 2MG 4 MO GCAVANDAMET TABS 500MG; 4MG 4 MO GCAVANDARYL TABS 1MG; 4MG 4 MO GCAVANDARYL TABS 2MG; 4MG 4 MO GCAVANDARYL TABS 2MG; 8MG 4 MO GCAVANDARYL TABS 4MG; 4MG 4 MO GCAVANDARYL TABS 4MG; 8MG 4 MO GCAVANDIA TABS 2MG 4 QL (60 EA per 30 days) GCAVANDIA TABS 4MG 4 QL (60 EA per 30 days) GCAVANDIA TABS 8MG 4 QL (30 EA per 30 days) GCBYDUREON INJ 2MG 3 QL (4 EA per 28 days) MOBYETTA INJ 10MCG/0.04ML 4 QL (2.4 ML per 28 days)BYETTA INJ 5MCG/0.02ML 4 QL (4.8 ML per 28 days)chlorpropamide tabs 100mg 2 QL (210 EA per 30 days) PA MOGCchlorpropamide tabs 250mg 2 QL (90 EA per 30 days) PA MOGCCYCLOSET TABS 0.8MG 4 QL (180 EA per 30 days)glimepiride tabs 1mg 1 QL (240 EA per 30 days) MO GCglimepiride tabs 2mg 1 QL (120 EA per 30 days) MO GCglimepiride tabs 4mg 1 QL (60 EA per 30 days) MO GCglipizide er tb24 10mg 1 QL (60 EA per 30 days) MO GCglipizide er tb24 2.5mg 1 QL (240 EA per 30 days) MO GCglipizide er tb24 5mg 1 QL (120 EA per 30 days) MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 44

Drug NameDrugTier Requirements/Limitsglipizide tabs 10mg 1 QL (120 EA per 30 days) MO GCglipizide tabs 5mg 1 QL (240 EA per 30 days) MO GCglyburide micronized tabs 1.5mg 1 QL (240 EA per 30 days) MO GCglyburide micronized tabs 3mg 1 QL (120 EA per 30 days) MO GCglyburide micronized tabs 6mg 1 QL (60 EA per 30 days) MO GCglyburide tabs 1.25mg 1 QL (480 EA per 30 days) MO GCglyburide tabs 2.5mg 1 QL (240 EA per 30 days) MO GCglyburide tabs 5mg 1 QL (120 EA per 30 days) MO GCGLYSET TABS 100MG 4 QL (90 EA per 30 days)GLYSET TABS 25MG 4 QL (90 EA per 30 days)GLYSET TABS 50MG 4 QL (90 EA per 30 days)JANUVIA TABS 100MG 3 QL (30 EA per 30 days) MO GCJANUVIA TABS 25MG 3 QL (30 EA per 30 days) MO GCJANUVIA TABS 50MG 3 QL (30 EA per 30 days) MO GCmetformin hcl er tb24 500mg 1 QL (120 EA per 30 days) MO GCmetformin hcl er tb24 750mg 1 QL (60 EA per 30 days) MO GCmetformin hcl tabs 1000mg 1 QL (60 EA per 30 days) MO GCmetformin hcl tabs 500mg 1 QL (150 EA per 30 days) MO GCmetformin hcl tabs 850mg 1 QL (90 EA per 30 days) MO GCnateglinide tabs 120mg 1 QL (90 EA per 30 days) MO GCnateglinide tabs 60mg 1 QL (90 EA per 30 days) MO GCONGLYZA TABS 2.5MG 4 QL (60 EA per 30 days) GCONGLYZA TABS 5MG 4 QL (30 EA per 30 days) GCpioglitazone hcl/metformin hcl tabs 500mg; 15mg 2 MO GCpioglitazone hcl/metformin hcl tabs 850mg; 15mg 2 MO GCpioglitazone hcl tabs 15mg 2 QL (30 EA per 30 days)pioglitazone hcl tabs 30mg 2 QL (30 EA per 30 days)pioglitazone hcl tabs 45mg 2 QL (30 EA per 30 days)PRANDIN TABS 0.5MG 4 QL (120 EA per 30 days)PRANDIN TABS 1MG 4 QL (120 EA per 30 days)PRANDIN TABS 2MG 4 QL (240 EA per 30 days)SYMLINPEN 120 INJ 2700MCG/2.7ML 4SYMLINPEN 60 INJ 1500MCG/1.5ML 4tolazamide tabs 500mg 1 QL (180 EA per 30 days) MO GCtolbutamide tabs 500mg 1 QL (180 EA per 30 days) MO GCTRADJENTA TABS 5MG 3 QL (30 EA per 30 days) MOVICTOZA INJ 18MG/3ML 4 QL (18 ML per 28 days)WELCHOL PACK 3.75GM 3 MOWELCHOL TABS 625MG 3 MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 45

Drug NameDrugTier Requirements/LimitsBlood Glucose Regulatorsglipizide/metformin hcl tabs 2.5mg; 250mg 1 QL (240 EA per 30 days) MO GCglipizide/metformin hcl tabs 2.5mg; 500mg 1 QL (120 EA per 30 days) MO GCglipizide/metformin hcl tabs 5mg; 500mg 1 QL (120 EA per 30 days) MO GCglyburide/metformin hcl tabs 1.25mg; 250mg 1 QL (240 EA per 30 days) MO GCglyburide/metformin hcl tabs 2.5mg; 500mg 1 QL (120 EA per 30 days) MO GCglyburide/metformin hcl tabs 5mg; 500mg 1 QL (120 EA per 30 days) MO GCJANUMET XR TB24 1000MG; 100MG 3 QL (30 EA per 30 days) MOJANUMET XR TB24 1000MG; 50MG 3 QL (30 EA per 30 days) MOJANUMET XR TB24 500MG; 50MG 3 QL (30 EA per 30 days) MOJANUMET TABS 1000MG; 50MG 3 QL (60 EA per 30 days) MOJANUMET TABS 500MG; 50MG 3 QL (60 EA per 30 days) MOKOMBIGLYZE XR TB24 1000MG; 2.5MG 4 QL (60 EA per 30 days)KOMBIGLYZE XR TB24 1000MG; 5MG 4 QL (30 EA per 30 days)KOMBIGLYZE XR TB24 500MG; 5MG 4 QL (30 EA per 30 days)PRANDIMET TABS 500MG; 1MG 4 QL (150 EA per 30 days)Glycemic AgentsGLUCAGEN HYPOKIT INJ 1MG 4GLUCAGON EMERGENCY KIT INJ 1MG 3 MOPROGLYCEM SUSP 50MG/ML 4InsulinsAPIDRA SOLOSTAR INJ 100UNIT/ML 4 MO GCAPIDRA INJ 100UNIT/ML 4 MO GCbd insulin syringe safetyglide/1ml/29g x 1/2" misc 2 MO GCbd insulin syringe ultrafine/0.3ml/31g x 5/16" misc 2 MObd insulin syringe ultrafine/0.5ml/30g x 1/2" misc 2 MObd insulin syringe ultrafine/1ml/31g x 5/16" misc 2 MObd pen needle/ultrafine/29g x 12.7mm misc 2 MOcurity gauze pads 2"x2" pads 2 MO GCHUMALOG KWIKPEN INJ 100UNIT/ML 3 GCHUMALOG MIX 50/50 KWIKPEN INJ 50UNIT/ML; 3 GC50UNIT/MLHUMALOG MIX 50/50 INJ 50UNIT/ML; 50UNIT/ML 3 GCHUMALOG MIX 75/25 KWIKPEN INJ 25UNIT/ML; 3 GC75UNIT/MLHUMALOG MIX 75/25 INJ 25UNIT/ML; 75UNIT/ML 3 GCHUMALOG INJ 100UNIT/ML 3 GCHUMULIN 70/30 PEN INJ 30UNIT/ML; 70UNIT/ML 3 MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 46

Drug NameDrugTier Requirements/LimitsHUMULIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 3 GCHUMULIN N U-100 PEN INJ 100UNIT/ML 3 GCHUMULIN N INJ 100UNIT/ML 3 GCHUMULIN R U-500 (CONCENTRATED) INJ 3 GC500UNIT/MLHUMULIN R INJ 100UNIT/ML 3 GCLANTUS SOLOSTAR INJ 100UNIT/ML 3 GCLANTUS INJ 100UNIT/ML 3 MO GCLEVEMIR FLEXPEN INJ 100UNIT/ML 3LEVEMIR INJ 100UNIT/ML 3NOVOLIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 3 GCNOVOLIN N INJ 100UNIT/ML 3 GCNOVOLIN R INJ 100UNIT/ML 3 GCNOVOLOG FLEXPEN INJ 100UNIT/ML 3 GCNOVOLOG MIX 70/30 PREFILLED FLEXPEN INJ 3 GC30UNIT/ML; 70UNIT/MLNOVOLOG MIX 70/30 INJ 30UNIT/ML; 70UNIT/ML 3 GCNOVOLOG INJ 100UNIT/ML 3 GCBlood Products/ Modifiers/ Volume ExpandersAnticoagulantsCOUMADIN TABS 10MG 4COUMADIN TABS 1MG 4COUMADIN TABS 2.5MG 4COUMADIN TABS 2MG 4COUMADIN TABS 3MG 4COUMADIN TABS 4MG 4COUMADIN TABS 5MG 4COUMADIN TABS 6MG 4COUMADIN TABS 7.5MG 4ENOXAPARIN SODIUM INJ 100MG/ML 5 QL (28 ML per 30 days)ENOXAPARIN SODIUM INJ 120MG/0.8ML 5 QL (28 ML per 30 days)ENOXAPARIN SODIUM INJ 150MG/ML 5 QL (28 ML per 30 days)enoxaparin sodium inj 30mg/0.3ml 2 QL (28 ML per 30 days) MO GCenoxaparin sodium inj 40mg/0.4ml 2 QL (28 ML per 30 days) MO GCenoxaparin sodium inj 60mg/0.6ml 2 QL (28 ML per 30 days) MO GCENOXAPARIN SODIUM INJ 80MG/0.8ML 4 QL (28 ML per 30 days)FONDAPARINUX SODIUM INJ 10MG/0.8ML 5 QL (14 ML per 28 days)FONDAPARINUX SODIUM INJ 2.5MG/0.5ML 4 QL (14 ML per 28 days)FONDAPARINUX SODIUM INJ 5MG/0.4ML 5 QL (14 ML per 28 days)PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 47

Drug NameDrugTier Requirements/LimitsFONDAPARINUX SODIUM INJ 7.5MG/0.6ML 5 QL (14 ML per 28 days)FRAGMIN INJ 12500UNIT/0.5ML 5 QL (14 ML per 28 days)FRAGMIN INJ 15000UNIT/0.6ML 5 QL (14 ML per 28 days)FRAGMIN INJ 18000UNT/0.72ML 5 QL (14 ML per 28 days)FRAGMIN INJ 2500UNIT/0.2ML 4 QL (14 ML per 28 days)FRAGMIN INJ 7500UNIT/0.3ML 5 QL (14 ML per 28 days)heparin sodium/nacl 0.45% inj 100unit/ml; 0.45% 1 B/D MO GCheparin sodium inj 10000unit/ml 1 B/D MO GCheparin sodium inj 1000unit/ml 1 B/D MO GCheparin sodium inj 20000unit/ml 1 B/D MO GCheparin sodium inj 5000unit/ml 1 B/D MO GCjantoven tabs 10mg 1 MO GCjantoven tabs 1mg 1 MO GCjantoven tabs 2.5mg 1 MO GCjantoven tabs 2mg 1 MO GCjantoven tabs 3mg 1 MO GCjantoven tabs 4mg 1 MO GCjantoven tabs 5mg 1 MO GCjantoven tabs 6mg 1 MO GCjantoven tabs 7.5mg 1 MO GCLOVENOX INJ 300MG/3ML 4 QL (28 ML per 30 days)PRADAXA CAPS 150MG 4PRADAXA CAPS 75MG 4warfarin sodium tabs 10mg 1 MO GCwarfarin sodium tabs 1mg 1 MO GCwarfarin sodium tabs 2.5mg 1 MO GCwarfarin sodium tabs 2mg 1 MO GCwarfarin sodium tabs 3mg 1 MO GCwarfarin sodium tabs 4mg 1 MO GCwarfarin sodium tabs 5mg 1 MO GCwarfarin sodium tabs 6mg 1 MO GCwarfarin sodium tabs 7.5mg 1 MO GCXARELTO TABS 10MG 3 QL (35 EA per 365 days) PA MOXARELTO TABS 15MG 3 QL (30 EA per 30 days) MOXARELTO TABS 20MG 3 QL (30 EA per 30 days) MOBlood Formation Modifiersanagrelide hydrochloride caps 0.5mg 2 MO GCanagrelide hydrochloride caps 1mg 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 48

Drug NameDrugTier Requirements/LimitsARANESP ALBUMIN FREE INJ 100MCG/ML 5 QL (4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 200MCG/ML 5 QL (1.6 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 25MCG/ML 4 QL (4 ML per 30 days) ST PAARANESP ALBUMIN FREE INJ 300MCG/0.6ML 5 QL (2.4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 40MCG/ML 4 QL (3.2 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 500MCG/ML 5 QL (1 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 60MCG/ML 4 QL (2.4 ML per 28 days) ST PALEUKINE INJ 250MCG 5 PANEULASTA INJ 6MG/0.6ML 5 PANEUPOGEN INJ 300MCG/0.5ML 5 PANEUPOGEN INJ 480MCG/0.8ML 5 PANEUPOGEN INJ 480MCG/1.6ML 5 PAPROCRIT INJ 10000UNIT/ML 4 QL (12 ML per 30 days) PAPROCRIT INJ 20000UNIT/ML 5 QL (12 ML per 30 days) PAPROCRIT INJ 2000UNIT/ML 4 QL (12 ML per 30 days) PAPROCRIT INJ 3000UNIT/ML 4 QL (12 ML per 30 days) PAPROCRIT INJ 40000UNIT/ML 5 QL (12 ML per 30 days) PAPROCRIT INJ 4000UNIT/ML 4 QL (12 ML per 30 days) PAPROMACTA TABS 12.5MG 5 QL (30 EA per 30 days) PAPROMACTA TABS 25MG 5 QL (30 EA per 30 days) PAPROMACTA TABS 50MG 5 QL (30 EA per 30 days) PAPROMACTA TABS 75MG 5 QL (30 EA per 30 days) PABlood Products/ Modifiers/ Volume ExpandersCINRYZE INJ 500UNIT 5 PANEUMEGA INJ 5MG 5 PACoagulantstranexamic acid inj 100mg/ml 2 MO GCPlatelet Modifying AgentsAGGRENOX CP12 25MG; 200MG 4 QL (60 EA per 30 days)cilostazol tabs 100mg 1 MO GCcilostazol tabs 50mg 1 MO GCclopidogrel tabs 300mg 2 MO GCclopidogrel tabs 75mg 2 QL (34 EA per 30 days) MO GCdipyridamole tabs 25mg 1 PA MO GCdipyridamole tabs 50mg 1 PA MO GCdipyridamole tabs 75mg 1 PA MO GCEFFIENT TABS 10MG 4 QL (36 EA per 30 days)EFFIENT TABS 5MG 4 QL (43 EA per 30 days)ticlopidine hcl tabs 250mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 49

Drug NameDrugTier Requirements/LimitsBlood Products/Modifiers/Volume ExpandersAnticoagulantsenoxaparin sodium inj 300mg/3ml 2 QL (28 ML per 30 days)enoxaparin sodium inj 300mg/3ml 2 QL (28 ML per 30 days)Cardiovascular AgentsAlpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr 2 MO GCclonidine hcl ptwk 0.2mg/24hr 2 MO GCclonidine hcl ptwk 0.3mg/24hr 2 MO GCclonidine hcl tabs 0.1mg 1 MO GCclonidine hcl tabs 0.2mg 1 MO GCclonidine hcl tabs 0.3mg 1 MO GCguanfacine hcl tabs 1mg 1 MO GCguanfacine hcl tabs 2mg 1 MO GCmethyldopa tabs 250mg 2 MO GCmethyldopa tabs 500mg 2 MO GCmidodrine hcl tabs 10mg 2 MO GCmidodrine hcl tabs 2.5mg 2 MO GCmidodrine hcl tabs 5mg 2 MO GCAlpha-adrenergic Blocking AgentsDIBENZYLINE CAPS 10MG 4doxazosin mesylate tabs 1mg 1 MO GCdoxazosin mesylate tabs 2mg 1 MO GCdoxazosin mesylate tabs 4mg 1 MO GCdoxazosin mesylate tabs 8mg 1 MO GCprazosin hcl caps 1mg 1 MO GCprazosin hcl caps 2mg 1 MO GCprazosin hcl caps 5mg 1 MO GCterazosin hcl caps 10mg 1 MO GCterazosin hcl caps 1mg 1 MO GCterazosin hcl caps 2mg 1 MO GCterazosin hcl caps 5mg 1 MO GCAngiotensin II Receptor AntagonistsBENICAR TABS 20MG 3 QL (30 EA per 30 days) MOBENICAR TABS 40MG 3 QL (30 EA per 30 days) MOBENICAR TABS 5MG 3 QL (30 EA per 30 days) MODIOVAN TABS 160MG 4DIOVAN TABS 320MG 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 50

Drug NameDrugTier Requirements/LimitsDIOVAN TABS 40MG 4DIOVAN TABS 80MG 4EDARBI TABS 40MG 4 QL (30 EA per 30 days) STEDARBI TABS 80MG 4 QL (30 EA per 30 days) STeprosartan mesylate tabs 600mg 2 MO GCirbesartan tabs 150mg 2 QL (30 EA per 30 days) MO GCirbesartan tabs 300mg 2 QL (30 EA per 30 days) MO GCirbesartan tabs 75mg 2 QL (30 EA per 30 days) MO GClosartan potassium tabs 100mg 1 MO GClosartan potassium tabs 25mg 1 MO GClosartan potassium tabs 50mg 1 MO GCMICARDIS TABS 20MG 3 QL (30 EA per 30 days) MOMICARDIS TABS 40MG 3 QL (30 EA per 30 days) MOMICARDIS TABS 80MG 3 QL (30 EA per 30 days) MOvalsartan/hydrochlorothiazide tabs 12.5mg; 160mg 2valsartan/hydrochlorothiazide tabs 12.5mg; 320mg 2valsartan/hydrochlorothiazide tabs 25mg; 320mg 2Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl tabs 10mg 1 MO GCbenazepril hcl tabs 20mg 1 MO GCbenazepril hcl tabs 40mg 1 MO GCbenazepril hcl tabs 5mg 1 MO GCcaptopril tabs 100mg 1 MO GCcaptopril tabs 12.5mg 1 MO GCcaptopril tabs 25mg 1 MO GCcaptopril tabs 50mg 1 MO GCenalapril maleate tabs 10mg 1 MO GCenalapril maleate tabs 2.5mg 1 MO GCenalapril maleate tabs 20mg 1 MO GCenalapril maleate tabs 5mg 1 MO GCfosinopril sodium tabs 10mg 1 MO GCfosinopril sodium tabs 20mg 1 MO GCfosinopril sodium tabs 40mg 1 MO GClisinopril tabs 10mg 1 MO GClisinopril tabs 2.5mg 1 MO GClisinopril tabs 20mg 1 MO GClisinopril tabs 30mg 1 MO GClisinopril tabs 40mg 1 MO GClisinopril tabs 5mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 51

Drug NameDrugTier Requirements/Limitsmoexipril hcl tabs 15mg 2 MO GCmoexipril hcl tabs 7.5mg 2 MO GCperindopril erbumine tabs 2mg 2 MO GCperindopril erbumine tabs 4mg 2 MO GCperindopril erbumine tabs 8mg 2 MO GCquinapril hcl tabs 10mg 1 MO GCquinapril hcl tabs 20mg 1 MO GCquinapril hcl tabs 40mg 1 MO GCquinapril hcl tabs 5mg 1 MO GCramipril caps 1.25mg 1 MO GCramipril caps 10mg 1 MO GCramipril caps 2.5mg 1 MO GCramipril caps 5mg 1 MO GCtrandolapril tabs 1mg 1 MO GCtrandolapril tabs 2mg 1 MO GCtrandolapril tabs 4mg 1 MO GCAntiarrhythmicsamiodarone hcl tabs 400mg 1 MO GCdisopyramide phosphate caps 100mg 1 MO GCdisopyramide phosphate caps 150mg 1 MO GCflecainide acetate tabs 100mg 1 MO GCflecainide acetate tabs 150mg 1 MO GCflecainide acetate tabs 50mg 1 MO GCmexiletine hcl caps 150mg 1 MO GCmexiletine hcl caps 200mg 1 MO GCmexiletine hcl caps 250mg 1 MO GCMULTAQ TABS 400MG 4NORPACE CR CP12 100MG 4PACERONE TABS 100MG 4pacerone tabs 200mg 1 MO GCpropafenone hcl er cp12 225mg 2 MO GCpropafenone hcl er cp12 325mg 2 MO GCpropafenone hcl er cp12 425mg 2 MO GCpropafenone hcl tabs 150mg 1 MO GCpropafenone hcl tabs 225mg 1 MO GCpropafenone hcl tabs 300mg 1 MO GCquinidine gluconate er tbcr 324mg 1 MO GCquinidine sulfate er tbcr 300mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 52

Drug NameDrugTier Requirements/Limitsquinidine sulfate tabs 200mg 1 MO GCquinidine sulfate tabs 300mg 1 MO GCsorine tabs 120mg 1 MO GCsorine tabs 160mg 1 MO GCsorine tabs 240mg 1 MO GCsorine tabs 80mg 1 MO GCsotalol hcl (af) tabs 120mg 1 MO GCsotalol hcl tabs 160mg 1 MO GCsotalol hcl tabs 240mg 1 MO GCsotalol hcl tabs 80mg 1 MO GCTIKOSYN CAPS 125MCG 4TIKOSYN CAPS 250MCG 4TIKOSYN CAPS 500MCG 4Beta-adrenergic Blocking Agentsacebutolol hcl caps 200mg 1 MO GCacebutolol hcl caps 400mg 1 MO GCatenolol tabs 100mg 1 MO GCatenolol tabs 25mg 1 MO GCatenolol tabs 50mg 1 MO GCbetaxolol hcl tabs 10mg 1 MObetaxolol hcl tabs 20mg 1 MO GCbisoprolol fumarate tabs 10mg 1 MO GCbisoprolol fumarate tabs 5mg 1 MO GCBYSTOLIC TABS 10MG 3 QL (120 EA per 30 days) MOBYSTOLIC TABS 2.5MG 3 QL (30 EA per 30 days) MOBYSTOLIC TABS 20MG 3 QL (60 EA per 30 days) MOBYSTOLIC TABS 5MG 3 QL (90 EA per 30 days) MOcarvedilol tabs 12.5mg 1 MO GCcarvedilol tabs 25mg 1 MO GCcarvedilol tabs 3.125mg 1 MO GCcarvedilol tabs 6.25mg 1 MO GCCOREG CR CP24 10MG 4 MOCOREG CR CP24 20MG 4 MOCOREG CR CP24 40MG 4 MOCOREG CR CP24 80MG 4 MOINNOPRAN XL CP24 120MG 4INNOPRAN XL CP24 80MG 4labetalol hcl tabs 100mg 1 MO GClabetalol hcl tabs 200mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 53

Drug NameDrugTier Requirements/Limitslabetalol hcl tabs 300mg 1 MO GCLEVATOL TABS 20MG 4metoprolol succinate er tb24 100mg 1 MO GCmetoprolol succinate er tb24 200mg 1 MO GCmetoprolol succinate er tb24 25mg 1 MO GCmetoprolol succinate er tb24 50mg 1 MO GCmetoprolol tartrate tabs 100mg 1 MO GCmetoprolol tartrate tabs 25mg 1 MO GCmetoprolol tartrate tabs 50mg 1 MO GCnadolol tabs 20mg 1 MO GCnadolol tabs 40mg 1 MO GCnadolol tabs 80mg 1 MO GCpindolol tabs 10mg 1 MO GCpindolol tabs 5mg 1 MO GCpropranolol hcl er cp24 120mg 1 MO GCpropranolol hcl er cp24 160mg 1 MO GCpropranolol hcl er cp24 60mg 1 MO GCpropranolol hcl er cp24 80mg 1 MO GCpropranolol hcl tabs 10mg 1 MO GCpropranolol hcl tabs 20mg 1 MO GCpropranolol hcl tabs 40mg 1 MO GCpropranolol hcl tabs 60mg 1 MO GCpropranolol hcl tabs 80mg 1 MO GCCalcium Channel Blocking Agentsafeditab cr tb24 30mg 1 MO GCafeditab cr tb24 60mg 1 MO GCamlodipine besylate tabs 10mg 1 MO GCamlodipine besylate tabs 2.5mg 1 MO GCamlodipine besylate tabs 5mg 1 MO GCcartia xt cp24 120mg 1 MO GCcartia xt cp24 180mg 1 MO GCcartia xt cp24 240mg 1 MO GCcartia xt cp24 300mg 1 MO GCdilt-cd cp24 120mg 1 MO GCdilt-cd cp24 300mg 1 MO GCdilt-xr cp24 180mg 1 MO GCdilt-xr cp24 240mg 1 MO GCdiltiazem cd cp24 120mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 54

Drug NameDrugTier Requirements/Limitsdiltiazem cd cp24 240mg 1 MO GCdiltiazem cd cp24 300mg 1 MO GCdiltiazem hcl er cp12 120mg 1 MO GCdiltiazem hcl er cp12 60mg 1 MO GCdiltiazem hcl er cp12 90mg 1 MO GCdiltiazem hcl er cp24 180mg 1 MO GCdiltiazem hcl er cp24 360mg 1 MO GCdiltiazem hcl tabs 120mg 1 MO GCdiltiazem hcl tabs 30mg 1 MO GCdiltiazem hcl tabs 60mg 1 MO GCdiltiazem hcl tabs 90mg 1 MO GCDYNACIRC CR TB24 10MG 4 QL (60 EA per 30 days)DYNACIRC CR TB24 5MG 4 QL (30 EA per 30 days)EXFORGE HCT TABS 10MG; 12.5MG; 160MG 4 MOEXFORGE HCT TABS 10MG; 25MG; 160MG 4 MOEXFORGE HCT TABS 10MG; 25MG; 320MG 4 MOEXFORGE HCT TABS 5MG; 12.5MG; 160MG 4 MOEXFORGE HCT TABS 5MG; 25MG; 160MG 4 MOEXFORGE TABS 10MG; 160MG 4 MOEXFORGE TABS 10MG; 320MG 4 MOEXFORGE TABS 5MG; 160MG 4 MOEXFORGE TABS 5MG; 320MG 4 MOfelodipine er tb24 10mg 1 MO GCfelodipine er tb24 2.5mg 1 MO GCfelodipine er tb24 5mg 1 MO GCisradipine caps 2.5mg 2 MO GCisradipine caps 5mg 2 MO GCmatzim la tb24 180mg 2 MO GCmatzim la tb24 240mg 2 MO GCmatzim la tb24 300mg 2 MO GCmatzim la tb24 360mg 2 MO GCmatzim la tb24 420mg 2 MO GCnicardipine hcl caps 20mg 1 MO GCnicardipine hcl caps 30mg 1 MO GCnifediac cc tb24 90mg 1 MO GCnifedical xl tb24 30mg 1 MO GCnifedical xl tb24 60mg 1 MO GCnifedipine er tb24 30mg 1 MO GCnifedipine er tb24 60mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 55

Drug NameDrugTier Requirements/Limitsnifedipine er tb24 90mg 1 MO GCnifedipine caps 10mg 2 PA MO GCnifedipine caps 20mg 2 PA MO GCNIMODIPINE CAPS 30MG 4nisoldipine er tb24 25.5mg 2 MO GCnisoldipine tb24 17mg 2 MO GCnisoldipine tb24 20mg 2 MO GCnisoldipine tb24 30mg 2 MO GCnisoldipine tb24 34mg 2 MO GCnisoldipine tb24 40mg 2 MO GCnisoldipine tb24 8.5mg 2 MO GCtaztia xt cp24 120mg 1 MO GCtaztia xt cp24 180mg 1 MO GCtaztia xt cp24 240mg 1 MO GCtaztia xt cp24 300mg 1 MO GCtaztia xt cp24 360mg 1 MO GCverapamil hcl er cp24 100mg 1 MO GCverapamil hcl er cp24 120mg 1 MO GCverapamil hcl er cp24 180mg 1 MO GCverapamil hcl er cp24 200mg 1 MO GCverapamil hcl er cp24 240mg 1 MO GCverapamil hcl er cp24 300mg 1 MO GCverapamil hcl er tbcr 120mg 1 MO GCverapamil hcl er tbcr 180mg 1 MO GCverapamil hcl er tbcr 240mg 1 MO GCverapamil hcl tabs 120mg 1 MO GCverapamil hcl tabs 40mg 1 MO GCverapamil hcl tabs 80mg 1 MO GCCardiovascular Agents, Otherdigoxin soln 0.05mg/ml 1 MO GCdigoxin tabs 0.125mg 1 MO GCdigoxin tabs 0.25mg 1 MO GCLANOXIN TABS 0.125MG 4LANOXIN TABS 0.25MG 4pentoxifylline er tbcr 400mg 1 MO GCRANEXA TB12 1000MG 3 QL (120 EA per 30 days) PA MORANEXA TB12 500MG 3 QL (120 EA per 30 days) PA MOTEKTURNA TABS 150MG 4 QL (30 EA per 30 days) STPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 56

Drug NameDrugTier Requirements/LimitsTEKTURNA TABS 300MG 4 QL (30 EA per 30 days) STCardiovascular AgentsADVICOR TB24 20MG; 1000MG 4 QL (60 EA per 30 days)ADVICOR TB24 20MG; 500MG 4 QL (60 EA per 30 days)ADVICOR TB24 20MG; 750MG 4 QL (60 EA per 30 days)ADVICOR TB24 40MG; 1000MG 4 QL (30 EA per 30 days)ALDACTAZIDE TABS 50MG; 50MG 4amiloride/hydrochlorothiazide tabs 5mg; 50mg 1 MO GCamlodipine besylate/benazepril hcl caps 10mg; 40mg 2 MO GCamlodipine besylate/benazepril hcl caps 5mg; 40mg 2 MO GCamlodipine besylate/benazepril hydrochloride caps 2 MO GC10mg; 20mgamlodipine besylate/benazepril hydrochloride caps 2 MO GC2.5mg; 10mgamlodipine besylate/benazepril hydrochloride caps 5mg; 2 MO GC10mgamlodipine besylate/benazepril hydrochloride caps 5mg; 2 MO GC20mgAMTURNIDE TABS 150MG; 5MG; 12.5MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 10MG; 12.5MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 10MG; 25MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 5MG; 12.5MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 5MG; 25MG 4 QL (30 EA per 30 days) STatenolol/chlorthalidone tabs 100mg; 25mg 1 MO GCatenolol/chlorthalidone tabs 50mg; 25mg 1 MO GCAZOR TABS 10MG; 20MG 3 QL (30 EA per 30 days) ST MOAZOR TABS 10MG; 40MG 3 QL (30 EA per 30 days) ST MOAZOR TABS 5MG; 20MG 3 QL (30 EA per 30 days) ST MOAZOR TABS 5MG; 40MG 3 QL (30 EA per 30 days) ST MObenazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg 1 MO GCbenazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg 1 MO GCbenazepril hcl/hydrochlorothiazide tabs 20mg; 25mg 1 MO GCbenazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg 1 MO GCBENICAR HCT TABS 12.5MG; 20MG 3 QL (30 EA per 30 days) ST MOBENICAR HCT TABS 12.5MG; 40MG 3 QL (30 EA per 30 days) ST MOBENICAR HCT TABS 25MG; 40MG 3 QL (30 EA per 30 days) ST MObisoprolol fumarate/hydrochlorothiazide tabs 10mg;6.25mg1 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 57

Drug NameDrugTier Requirements/Limitsbisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 1 MO GC6.25mgbisoprolol fumarate/hydrochlorothiazide tabs 5mg; 1 MO GC6.25mgcaptopril/hydrochlorothiazide tabs 25mg; 15mg 1 MO GCcaptopril/hydrochlorothiazide tabs 25mg; 25mg 1 MO GCcaptopril/hydrochlorothiazide tabs 50mg; 15mg 1 MO GCcaptopril/hydrochlorothiazide tabs 50mg; 25mg 1 MO GCCLORPRES TABS 15MG; 0.1MG 4 QL (60 EA per 30 days)CLORPRES TABS 15MG; 0.2MG 4 QL (60 EA per 30 days)enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg 1 MO GCenalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg 1 MO GCfosinopril sodium/hydrochlorothiazide tabs 10mg; 1 MO GC12.5mgfosinopril sodium/hydrochlorothiazide tabs 20mg; 1 MO GC12.5mgirbesartan/hydrochlorothiazide tabs 12.5mg; 150mg 2 QL (60 EA per 30 days) MO GCirbesartan/hydrochlorothiazide tabs 12.5mg; 300mg 2 QL (60 EA per 30 days) MO GClisinopril/hydrochlorothiazide tabs 12.5mg; 10mg 1 MO GClisinopril/hydrochlorothiazide tabs 12.5mg; 20mg 1 MO GClisinopril/hydrochlorothiazide tabs 25mg; 20mg 1 MO GClosartan potassium/hydrochlorothiazide tabs 12.5mg; 1 MO GC100mglosartan potassium/hydrochlorothiazide tabs 12.5mg; 1 MO GC50mglosartan potassium/hydrochlorothiazide tabs 25mg; 1 MO GC100mgmethyldopa/hydrochlorothiazide tabs 15mg; 250mg 2 MO GCmethyldopa/hydrochlorothiazide tabs 25mg; 250mg 2 MO GCmetoprolol/hydrochlorothiazide tabs 25mg; 100mg 1 MO GCmetoprolol/hydrochlorothiazide tabs 25mg; 50mg 1 MO GCmetoprolol/hydrochlorothiazide tabs 50mg; 100mg 1 MO GCMICARDIS HCT TABS 12.5MG; 40MG 4 QL (30 EA per 30 days) STMICARDIS HCT TABS 12.5MG; 80MG 4 QL (30 EA per 30 days) STMICARDIS HCT TABS 25MG; 80MG 4 QL (30 EA per 30 days) STmoexipril/hydrochlorothiazide tabs 12.5mg; 15mg 2 MO GCmoexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg 2 MO GCmoexipril/hydrochlorothiazide tabs 25mg; 15mg 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 58

Drug NameDrugTier Requirements/Limitsnadolol/bendroflumethiazide tabs 5mg; 40mg 2 MO GCnadolol/bendroflumethiazide tabs 5mg; 80mg 2 MO GCpropranolol/hydrochlorothiazide tabs 25mg; 40mg 1 MO GCpropranolol/hydrochlorothiazide tabs 25mg; 80mg 1 MO GCquinapril/hydrochlorothiazide tabs 12.5mg; 10mg 1 MO GCquinapril/hydrochlorothiazide tabs 12.5mg; 20mg 1 MO GCquinapril/hydrochlorothiazide tabs 25mg; 20mg 1 MO GCreserpine tabs 0.1mg 2 MO GCreserpine tabs 0.25mg 2 MO GCSIMCOR TB24 500MG; 20MG 4 QL (30 EA per 30 days)SIMCOR TB24 750MG; 20MG 4 QL (30 EA per 30 days)spironolactone/hydrochlorothiazide tabs 25mg; 25mg 1 MO GCTARKA TBCR 1MG; 240MG 4TEKAMLO TABS 150MG; 5MG 4 QL (30 EA per 30 days) STTEKAMLO TABS 300MG; 10MG 4 QL (30 EA per 30 days) STTEKAMLO TABS 300MG; 5MG 4 QL (30 EA per 30 days) STTEKTURNA HCT TABS 150MG; 12.5MG 4 QL (30 EA per 30 days) STTEKTURNA HCT TABS 150MG; 25MG 4 QL (30 EA per 30 days) STTEKTURNA HCT TABS 300MG; 12.5MG 4 QL (30 EA per 30 days) STTEKTURNA HCT TABS 300MG; 25MG 4 QL (30 EA per 30 days) STtriamterene/hydrochlorothiazide caps 25mg; 37.5mg 1 MO GCtriamterene/hydrochlorothiazide caps 25mg; 50mg 1 MO GCtriamterene/hydrochlorothiazide tabs 25mg; 37.5mg 1 MO GCtriamterene/hydrochlorothiazide tabs 50mg; 75mg 1 MO GCTRIBENZOR TABS 5MG; 12.5MG; 40MG 3 QL (30 EA per 30 days) ST MOTWYNSTA TABS 10MG; 40MG 3 QL (30 EA per 30 days) ST MOTWYNSTA TABS 10MG; 80MG 3 QL (30 EA per 30 days) ST MOTWYNSTA TABS 5MG; 40MG 3 QL (30 EA per 30 days) ST MOTWYNSTA TABS 5MG; 80MG 3 QL (30 EA per 30 days) ST MOVYTORIN TABS 10MG; 10MG 4 QL (30 EA per 30 days) STVYTORIN TABS 10MG; 20MG 4 QL (30 EA per 30 days) STVYTORIN TABS 10MG; 40MG 4 QL (30 EA per 30 days) STVYTORIN TABS 10MG; 80MG 4 QL (30 EA per 30 days) ST PADiuretics, Carbonic Anhydrase Inhibitorsacetazolamide er cp12 500mg 2 MO GCacetazolamide tabs 125mg 1 MO GCacetazolamide tabs 250mg 1 MO GCmethazolamide tabs 25mg 1 MO GCmethazolamide tabs 50mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 59

Drug NameDrugTier Requirements/LimitsDiuretics, Loopbumetanide inj 0.25mg/ml 1 MO GCbumetanide tabs 0.5mg 1 MO GCbumetanide tabs 1mg 1 MO GCbumetanide tabs 2mg 1 MO GCEDECRIN TABS 25MG 4furosemide inj 10mg/ml 1 MO GCfurosemide soln 10mg/ml 1 MO GCfurosemide tabs 20mg 1 MO GCfurosemide tabs 40mg 1 MO GCfurosemide tabs 80mg 1 MO GCtorsemide tabs 100mg 1 MO GCtorsemide tabs 10mg 1 MO GCtorsemide tabs 20mg 1 MO GCtorsemide tabs 5mg 1 MO GCDiuretics, Potassium-sparingamiloride hcl tabs 5mg 1 MO GCDYRENIUM CAPS 100MG 4DYRENIUM CAPS 50MG 4eplerenone tabs 25mg 2 MO GCeplerenone tabs 50mg 2 MO GCspironolactone tabs 100mg 1 MO GCspironolactone tabs 25mg 1 MO GCspironolactone tabs 50mg 1 MO GCDiuretics, Thiazidechlorothiazide tabs 250mg 1 MO GCchlorothiazide tabs 500mg 1 MO GCchlorthalidone tabs 25mg 1 MO GCchlorthalidone tabs 50mg 1 MO GChydrochlorothiazide caps 12.5mg 1 MO GChydrochlorothiazide tabs 12.5mg 1 MO GChydrochlorothiazide tabs 25mg 1 MO GChydrochlorothiazide tabs 50mg 1 MO GCindapamide tabs 1.25mg 1 MO GCindapamide tabs 2.5mg 1 MO GCmethyclothiazide tabs 5mg 1 MO GCmetolazone tabs 10mg 1 MO GCmetolazone tabs 2.5mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 60

Drug NameDrugTier Requirements/Limitsmetolazone tabs 5mg 1 MO GCTHALITONE TABS 15MG 4Dyslipidemics, Fibric Acid DerivativesANTARA CAPS 130MG 3 ST MOANTARA CAPS 43MG 3 ST MOfenofibrate micronized caps 134mg 1 MO GCfenofibrate micronized caps 200mg 1 MO GCfenofibrate micronized caps 67mg 1 MO GCfenofibrate tabs 145mg 2 MOfenofibrate tabs 160mg 1 MO GCfenofibrate tabs 48mg 2 MOfenofibrate tabs 54mg 1 MO GCFENOGLIDE TABS 120MG 4 STFENOGLIDE TABS 40MG 4 STgemfibrozil tabs 600mg 1 QL (60 EA per 30 days) MO GCLIPOFEN CAPS 150MG 3 ST MOLOFIBRA TABS 160MG 4 STNALFON CAPS 400MG 4TRILIPIX CPDR 135MG 4 STTRILIPIX CPDR 45MG 4 STDyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium tabs 10mg 2 MO GCatorvastatin calcium tabs 20mg 2 MO GCatorvastatin calcium tabs 40mg 2 MO GCatorvastatin calcium tabs 80mg 2 MO GCCRESTOR TABS 10MG 3 QL (30 EA per 30 days) MOCRESTOR TABS 20MG 3 QL (30 EA per 30 days) MOCRESTOR TABS 40MG 3 QL (30 EA per 30 days) MOCRESTOR TABS 5MG 3 QL (30 EA per 30 days) MOfluvastatin caps 20mg 2 QL (30 EA per 30 days) MO GCfluvastatin caps 40mg 2 QL (60 EA per 30 days) MO GCLESCOL XL TB24 80MG 4 QL (30 EA per 30 days) STLIVALO TABS 1MG 4 QL (30 EA per 30 days) STLIVALO TABS 2MG 4 QL (30 EA per 30 days) STLIVALO TABS 4MG 4 QL (30 EA per 30 days) STlovastatin tabs 10mg 1 MO GClovastatin tabs 20mg 1 MO GClovastatin tabs 40mg 1 MO GCpravastatin sodium tabs 10mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 61

Drug NameDrugTier Requirements/Limitspravastatin sodium tabs 20mg 1 MO GCpravastatin sodium tabs 40mg 1 MO GCpravastatin sodium tabs 80mg 1 MO GCsimvastatin tabs 10mg 1 MO GCsimvastatin tabs 20mg 1 MO GCsimvastatin tabs 40mg 1 MO GCsimvastatin tabs 5mg 1 MO GCsimvastatin tabs 80mg 1 PA MO GCDyslipidemics, Othercholestyramine light pack 4gm 1 MO GCcolestipol hcl gran 5gm 1 MO GCcolestipol hcl tabs 1gm 1 MO GCLOVAZA CAPS 375MG; 465MG; 1GM 4 QL (120 EA per 30 days)niacor tabs 500mg 1 MO GCNIASPAN TBCR 1000MG 3 QL (60 EA per 30 days) MONIASPAN TBCR 500MG 3 QL (60 EA per 30 days) MONIASPAN TBCR 750MG 3 QL (60 EA per 30 days) MOprevalite powd 4gm/dose 1 MO GCSIMCOR TB24 1000MG; 40MG 3 QL (60 EA per 30 days) MOSIMCOR TB24 500MG; 40MG 3 QL (60 EA per 30 days) MOZETIA TABS 10MG 4Vasodilators, Direct-acting Arterial/ VenousDILATRATE SR CPCR 40MG 4ISORDIL TITRADOSE TABS 40MG 4isosorbide dinitrate er tbcr 40mg 1 MO GCisosorbide dinitrate subl 2.5mg 1 MO GCisosorbide dinitrate subl 5mg 1 MO GCisosorbide dinitrate tabs 10mg 1 MO GCisosorbide dinitrate tabs 20mg 1 MO GCisosorbide dinitrate tabs 30mg 1 MO GCisosorbide dinitrate tabs 5mg 1 MO GCisosorbide mononitrate er tb24 120mg 1 MO GCisosorbide mononitrate er tb24 30mg 1 MO GCisosorbide mononitrate er tb24 60mg 1 MO GCisosorbide mononitrate tabs 20mg 1 MO GCminitran pt24 0.1mg/hr 1 MO GCminitran pt24 0.2mg/hr 1 MO GCminitran pt24 0.4mg/hr 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 62

Drug NameDrugTier Requirements/Limitsminitran pt24 0.6mg/hr 1 MO GCNITRO-BID OINT 2% 3 MOnitroglycerin transdermal pt24 0.1mg/hr 1 MO GCnitroglycerin pt24 0.2mg/hr 1 MO GCnitroglycerin pt24 0.4mg/hr 1 MO GCnitroglycerin pt24 0.6mg/hr 1 MO GCnitrolingual pumpspray soln 0.4mg/spray 2 MO GCNITROMIST AERS 400MCG/SPRAY 4NITROSTAT SUBL 0.3MG 3 MONITROSTAT SUBL 0.4MG 3 MONITROSTAT SUBL 0.6MG 3 MOVasodilators, Direct-acting Arterial/Venousisosorbide mononitrate tabs 10mg 1 MOnitroglycerin lingual aers 400mcg/spray 2nitroglycerin lingual aers 400mcg/spray 2Vasodilators, Direct-acting Arterialhydralazine hcl tabs 100mg 1 MO GChydralazine hcl tabs 10mg 1 MO GChydralazine hcl tabs 25mg 1 MO GChydralazine hcl tabs 50mg 1 MO GCminoxidil tabs 10mg 1 MO GCminoxidil tabs 2.5mg 1 MO GCCentral Nervous System AgentsAttention Deficit Hyperactivity Disorder Agents,Amphetaminesadderall xr cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg 2 QL (30 EA per 30 days) PA MOGCADDERALL XR CP24 2.5MG; 2.5MG; 2.5MG; 2.5MG 4 QL (30 EA per 30 days) PAADDERALL XR CP24 3.75MG; 3.75MG; 3.75MG; 4 QL (30 EA per 30 days) PA3.75MGADDERALL XR CP24 5MG; 5MG; 5MG; 5MG 4 QL (30 EA per 30 days) PAADDERALL XR CP24 6.25MG; 6.25MG; 6.25MG; 4 QL (30 EA per 30 days) PA6.25MGADDERALL XR CP24 7.5MG; 7.5MG; 7.5MG; 7.5MG 4 QL (30 EA per 30 days) PAamphetamine/dextroamphetamine cp24 1.25mg; 2 QL (30 EA per 30 days) PA MO1.25mg; 1.25mg; 1.25mgamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg;2.5mg; 2.5mg2 QL (30 EA per 30 days) PA MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 63

Drug NameDrugTier Requirements/Limitsamphetamine/dextroamphetamine cp24 3.75mg; 2 QL (30 EA per 30 days) PA MO3.75mg; 3.75mg; 3.75mgamphetamine/dextroamphetamine cp24 5mg; 5mg; 5mg; 2 QL (30 EA per 30 days) PA MO5mgamphetamine/dextroamphetamine cp24 6.25mg; 2 QL (30 EA per 30 days) PA MO6.25mg; 6.25mg; 6.25mgamphetamine/dextroamphetamine cp24 7.5mg; 7.5mg; 2 QL (30 EA per 30 days) PA MO7.5mg; 7.5mgamphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1 PA MO GC1.25mg; 1.25mgamphetamine/dextroamphetamine tabs 1.875mg; 1 PA MO GC1.875mg; 1.875mg; 1.875mgamphetamine/dextroamphetamine tabs 2.5mg; 2.5mg; 1 PA MO GC2.5mg; 2.5mgamphetamine/dextroamphetamine tabs 3.125mg; 1 PA MO GC3.125mg; 3.125mg; 3.125mgamphetamine/dextroamphetamine tabs 3.75mg; 3.75mg; 1 PA MO GC3.75mg; 3.75mgamphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 1 PA MO GC5mgamphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 1 PA MO GC7.5mg; 7.5mgdextroamphetamine sulfate er cp24 10mg 2 PA MO GCdextroamphetamine sulfate er cp24 15mg 2 PA MO GCdextroamphetamine sulfate er cp24 5mg 2 PA MO GCdextroamphetamine sulfate tabs 10mg 1 PA MO GCdextroamphetamine sulfate tabs 5mg 1 PA MO GCmethamphetamine hcl tabs 5mg 2 PA MO GCAttention Deficit Hyperactivity Disorder Agents, NonamphetaminesDAYTRANA PTCH 10MG/9HR 4 QL (30 EA per 30 days) PADAYTRANA PTCH 15MG/9HR 4 QL (30 EA per 30 days) PADAYTRANA PTCH 20MG/9HR 4 QL (30 EA per 30 days) PADAYTRANA PTCH 30MG/9HR 4 QL (30 EA per 30 days) PAdexmethylphenidate hcl tabs 10mg 1 MO GCdexmethylphenidate hcl tabs 2.5mg 1 MO GCdexmethylphenidate hcl tabs 5mg 1 MO GCFOCALIN XR CP24 10MG 4 QL (30 EA per 30 days) PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 64

Drug NameDrugTier Requirements/LimitsFOCALIN XR CP24 15MG 4 QL (30 EA per 30 days) PAFOCALIN XR CP24 20MG 4 QL (60 EA per 30 days) PAINTUNIV TB24 1MG 4INTUNIV TB24 2MG 4INTUNIV TB24 3MG 4INTUNIV TB24 4MG 4METADATE CD CPCR 10MG 4 QL (60 EA per 30 days) PAMETADATE CD CPCR 20MG 4 QL (60 EA per 30 days) PAMETADATE CD CPCR 60MG 4 QL (30 EA per 30 days) PAmetadate er tbcr 20mg 1 PA MO GCmethylphenidate hcl cd cpcr 10mg 2 QL (60 EA per 30 days)methylphenidate hcl cd cpcr 20mg 2 QL (60 EA per 30 days)methylphenidate hcl cd cpcr 20mg 2 QL (60 EA per 30 days)methylphenidate hcl cd cpcr 60mg 2 QL (30 EA per 30 days)methylphenidate hcl er tbcr 20mg 1 PA MO GCmethylphenidate hcl tabs 10mg 1 PA MO GCmethylphenidate hcl tabs 20mg 1 PA MO GCmethylphenidate hcl tabs 5mg 1 PA MO GCmethylphenidate hydrochloride soln 10mg/5ml 2 PA MO GCmethylphenidate hydrochloride soln 5mg/5ml 2 PA MO GCSTRATTERA CAPS 100MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 10MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 18MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 25MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 40MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 60MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 80MG 4 QL (30 EA per 30 days) PACentral Nervous System, OtherNUEDEXTA CAPS 20MG; 10MG 3 QL (60 EA per 30 days) MORILUTEK TABS 50MG 5 PAXENAZINE TABS 12.5MG 5 QL (124 EA per 25 days) PA LAXENAZINE TABS 25MG 5 QL (124 EA per 25 days) PA LAFibromyalgia AgentsSAVELLA TITRATION PACK MISC 0 3 QL (55 EA per 28 days) MOSAVELLA TABS 100MG 3 QL (60 EA per 30 days) MOSAVELLA TABS 12.5MG 3 QL (60 EA per 30 days) MOSAVELLA TABS 25MG 3 QL (60 EA per 30 days) MOSAVELLA TABS 50MG 3 QL (60 EA per 30 days) MOMultiple Sclerosis AgentsPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 65

Drug NameDrugTier Requirements/LimitsAMPYRA TB12 10MG 5 QL (60 EA per 30 days) PA LAAUBAGIO TABS 14MG 5 QL (30 EA per 30 days) PA MOAUBAGIO TABS 7MG 5 QL (30 EA per 30 days) PA MOAVONEX INJ 30MCG/0.5ML 5 QL (4 EA per 28 days) PAAVONEX INJ 30MCG/VIAL 5 QL (4 EA per 28 days) PABETASERON INJ 0.3MG 5 QL (15 EA per 28 days) PACOPAXONE INJ 20MG/ML 5 QL (30 EA per 30 days) PAEXTAVIA INJ 0.3MG 5 QL (15 EA per 28 days) PAGILENYA CAPS 0.5MG 5 QL (28 EA per 28 days) PAREBIF TITRATION PACK INJ 0 5 QL (4.2 ML per 28 days) PAREBIF INJ 22MCG/0.5ML 5 QL (6 ML per 28 days) PAREBIF INJ 44MCG/0.5ML 5 QL (6 ML per 28 days) PATYSABRI INJ 300MG/15ML 5 PA LADental and Oral AgentsDental and Oral Agentscevimeline hcl caps 30mg 2chlorhexidine gluconate oral rinse soln 0.12% 1 MO GCEVOXAC CAPS 30MG 4minocycline hcl caps 50mg 1 MO GCperiogard soln 0.12% 1 MO GCpilocarpine hcl tabs 7.5mg 2 MO GCpilocarpine hydrochloride tabs 5mg 2 MO GCtriamcinolone in orabase pste 0.1% 2 MO GCDermatological AgentsDermatological Agentsadapalene crea 0.1% 2 PA MO GCadapalene gel 0.1% 2 PA MO GCammonium lactate crea 12% 1 MO GCammonium lactate lotn 12% 1 MO GCamnesteem caps 10mg 2 MO GCamnesteem caps 20mg 2 MO GCamnesteem caps 40mg 2 MO GCAZELEX CREA 20% 4betamethasone dipropionate lotn 0.05% 1 MO GCcalcipotriene crea 0.005% 2calcipotriene oint 0.005% 2 MO GCcalcipotriene soln 0.005% 2 MO GCcalcitriol oint 3mcg/gm 2PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 66

Drug NameDrugTier Requirements/LimitsCARAC CREA 0.5% 4claravis caps 10mg 2 MO GCclaravis caps 20mg 2 MO GCCLARAVIS CAPS 30MG 5claravis caps 40mg 2 MO GCclindamycin/benzoyl peroxide gel 5%; 1% 2 MO GCclotrimazole/betamethasone dipropionate crea 0.05%; 1 MO GC1%clotrimazole/betamethasone dipropionate lotn 0.05%; 1 MO GC1%CONDYLOX GEL 0.5% 4CORTISPORIN CREA 0.5%; 0.5%; 10000UNIT/GM 4CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%; 45000UNIT/GMDOVONEX CREA 0.005% 4ELIDEL CREA 1% 4 QL (100 GM per 30 days)erythromycin/benzoyl peroxide gel 5%; 3% 2 MO GCFINACEA GEL 15% 4FLUOROPLEX CREA 1% 4fluorouracil crea 5% 2 MO GCfluorouracil inj 2.5gm/50ml 2 MO GCfluorouracil soln 2% 2fluorouracil soln 5% 2imiquimod crea 5% 1 MO GClaclotion lotn 12% 1 MO GCnystatin/triamcinolone crea 100000unit/gm; 0.1% 1 MO GCnystatin/triamcinolone oint 100000unit/gm; 0.1% 1 MO GCOXSORALEN ULTRA CAPS 10MG 4PHISOHEX LIQD 3% 3 MOpodofilox soln 0.5% 1 MO GCPROTOPIC OINT 0.03% 4 QL (100 GM per 30 days)PROTOPIC OINT 0.1% 4 QL (60 GM per 30 days)REGRANEX GEL 0.01% 5 QL (30 GM per 30 days) PASANTYL OINT 250UNIT/GM 4selenium sulfide lotn 2.5% 2 MO GCSOLARAZE GEL 3% 4SORIATANE CAPS 10MG 5 QL (60 EA per 30 days) PASORIATANE CAPS 17.5MG 5 QL (60 EA per 30 days) PASORIATANE CAPS 25MG 5 QL (60 EA per 30 days) PAPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 67

Drug NameDrugTier Requirements/LimitsSTELARA INJ 45MG/0.5ML 5 PASTELARA INJ 90MG/ML 5 PATACLONEX OINT 0.064%; 0.005% 4TACLONEX SUSP 0.064%; 0.005% 4TAZORAC CREA 0.05% 4TAZORAC CREA 0.1% 4TAZORAC GEL 0.05% 4TAZORAC GEL 0.1% 4VECTICAL OINT 3MCG/GM 4VEREGEN OINT 15% 4VOLTAREN GEL 1% 4ZONALON CREA 5% 4ZYCLARA CREA 3.75% 4Enzyme Replacement/ ModifiersEnzyme Replacement/ ModifiersADAGEN INJ 250UNIT/ML 4ALDURAZYME INJ 2.9MG/5ML 5 PA LABUPHENYL POWD 0 5BUPHENYL TABS 500MG 5CARBAGLU TABS 200MG 5 PACEREZYME INJ 200UNIT 4CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT 3 MOCREON CPEP 15000UNIT; 3000UNIT; 9500UNIT 3 MOCREON CPEP 30000UNIT; 6000UNIT; 19000UNIT 3 MOCREON CPEP 60000UNIT; 12000UNIT; 38000UNIT 3 MOFABRAZYME INJ 35MG 5 PA LAKUVAN TBSO 100MG 5 PAMYOZYME INJ 50MG 5 PANAGLAZYME INJ 1MG/ML 5 PA LAORFADIN CAPS 10MG 5ORFADIN CAPS 2MG 5ORFADIN CAPS 5MG 5PANCREAZE CPEP 17500UNIT; 4200UNIT; 410000UNITPANCREAZE CPEP 43750UNIT; 10500UNIT; 425000UNITPANCREAZE CPEP 61000UNIT; 21000UNIT;37000UNIT4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 68

Drug NameDrugTier Requirements/LimitsPANCREAZE CPEP 70000UNIT; 16800UNIT; 440000UNITZAVESCA CAPS 100MG 5ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT 3 MOZENPEP CPEP 136000UNIT; 25000UNIT; 85000UNIT 3 MOZENPEP CPEP 27000UNIT; 5000UNIT; 17000UNIT 3 MOZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT 3 MOZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT 3 MOEnzyme Replacement/ModifiersEnzyme Replacement/ModifiersPERTZYE CPEP 30250UNIT; 8000UNIT; 28750UNIT 4 MOPERTZYE CPEP 60500UNIT; 16000UNIT; 57500UNIT 4 MOVIOKACE TABS 39150UNIT; 10440UNIT; 39150UNIT 4 MOVIOKACE TABS 78300UNIT; 20880UNIT; 78300UNIT 4 MOGastrointestinal AgentsAntispasmodics, Gastrointestinaldicyclomine hcl caps 10mg 1 PA MO GCdicyclomine hcl soln 10mg/5ml 1 PA MO GCdicyclomine hcl tabs 20mg 1 PA MO GCglycopyrrolate inj 0.2mg/ml 1 MO GCglycopyrrolate tabs 1mg 2 MO GCglycopyrrolate tabs 2mg 2 MO GCmethscopolamine bromide tabs 2.5mg 2 MO GCmethscopolamine bromide tabs 5mg 2 MO GCGastrointestinal Agents, OtherCHENODAL TABS 250MG 5diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml 1 PA MO GCdiphenoxylate/atropine tabs 0.025mg; 2.5mg 1 PA MO GCloperamide hcl caps 2mg 1 MO GCRELISTOR INJ 12MG/0.6ML 4 QL (18 EA per 30 days) PAursodiol caps 300mg 1 MO GCGastrointestinal Agentsgavilyte-c solr 240gm; 2.98gm; 6.72gm; 5.84gm; 1 MO GC22.72gmgavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm; 1 MO GC22.74gmgavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm; 1 MO GC11.2gmHELIDAC MISC 0; 0; 0 4 QL (56 EA per 30 days)PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 69

Drug NameDrugTier Requirements/LimitsPREVPAC MISC 500MG; 500MG; 30MG 4 QL (14 EA per 30 days)PYLERA CAPS 140MG; 125MG; 125MG 4 QL (120 EA per 30 days)trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm 1 MO GCHistamine2 (H2) Receptor Antagonistscimetidine hcl soln 300mg/5ml 1 MO GCcimetidine tabs 200mg 1 MO GCcimetidine tabs 300mg 1 MO GCcimetidine tabs 400mg 1 MO GCcimetidine tabs 800mg 1 MO GCfamotidine inj 10mg/ml 1 MO GCfamotidine susr 40mg/5ml 1 MO GCfamotidine tabs 20mg 1 MO GCfamotidine tabs 40mg 1 MO GCnizatidine caps 150mg 1 MO GCnizatidine caps 300mg 1 MO GCnizatidine soln 15mg/ml 1 MO GCranitidine hcl caps 150mg 1 MO GCranitidine hcl caps 300mg 1 MO GCranitidine hcl syrp 15mg/ml 1 MO GCranitidine hcl tabs 150mg 1 MO GCranitidine hcl tabs 300mg 1 MO GCIrritable Bowel Syndrome AgentsAMITIZA CAPS 24MCG 4 QL (60 EA per 30 days) STAMITIZA CAPS 8MCG 4 QL (60 EA per 30 days) STbudesonide cp24 3mg 2 MO GCLINZESS CAPS 145MCG 4 QL (30 EA per 30 days) PA MOLINZESS CAPS 290MCG 4 QL (30 EA per 30 days) PA MOLOTRONEX TABS 0.5MG 3 QL (60 EA per 30 days) PA MOLOTRONEX TABS 1MG 3 QL (60 EA per 30 days) PA MOLaxativesCOLYTE-FLAVOR PACKS SOLR 240GM; 2.98GM; 46.72GM; 5.84GM; 22.72GMconstulose soln 10gm/15ml 1 MOenulose soln 10gm/15ml 1 MO GCgenerlac soln 10gm/15ml 1 MOGOLYTELY SOLR 227.1GM; 2.82GM; 6.36GM;5.53GM; 21.5GM4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 70

Drug NameDrugTier Requirements/LimitsGOLYTELY SOLR 236GM; 2.97GM; 6.74GM; 5.86GM; 422.74GMHALFLYTELY BOWEL PREP/FLAVOR PACKS KIT 45MG; 210GM; 0.74GM; 2.86GM; 5.6GMKRISTALOSE PACK 10GM 4 MOKRISTALOSE PACK 20GM 4 MOlactulose soln 10gm/15ml 1 MO GCMOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM; 42.691GM; 7.5GMpolyethylene glycol 3350 powd 0 1 MO GCProtectantsCARAFATE SUSP 1GM/10ML 4misoprostol tabs 100mcg 2misoprostol tabs 100mcg 2misoprostol tabs 100mcg 2misoprostol tabs 100mcg 2misoprostol tabs 200mcg 1 MO GCsucralfate tabs 1gm 1 MO GCProton Pump InhibitorsDEXILANT CPDR 30MG 4 QL (30 EA per 30 days) STDEXILANT CPDR 60MG 4 QL (30 EA per 30 days) STlansoprazole cpdr 15mg 2 QL (30 EA per 30 days) MO GClansoprazole cpdr 30mg 2 QL (30 EA per 30 days) MO GCNEXIUM I.V. INJ 20MG 4NEXIUM I.V. INJ 40MG 4NEXIUM CPDR 20MG 3 QL (30 EA per 30 days) MONEXIUM CPDR 40MG 3 QL (30 EA per 30 days) MONEXIUM PACK 10MG 3 QL (30 EA per 30 days) MONEXIUM PACK 20MG 3 QL (30 EA per 30 days) MONEXIUM PACK 40MG 3 QL (30 EA per 30 days) MOomeprazole cpdr 10mg 1 MO GComeprazole cpdr 20mg 1 MO GComeprazole cpdr 40mg 1 MO GCpantoprazole sodium tbec 20mg 1 MO GCpantoprazole sodium tbec 40mg 1 MO GCGenitourinary AgentsAntispasmodics, UrinaryDETROL LA CP24 2MG 4 QL (30 EA per 30 days)DETROL LA CP24 4MG 4 QL (30 EA per 30 days)PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 71

Drug NameDrugTier Requirements/LimitsDETROL TABS 1MG 4 QL (60 EA per 30 days)DETROL TABS 2MG 4 QL (60 EA per 30 days)ENABLEX TB24 15MG 3 QL (30 EA per 30 days) MOENABLEX TB24 7.5MG 3 QL (30 EA per 30 days) MOflavoxate hcl tabs 100mg 1 MO GCGELNIQUE GEL 10% 4 QL (30 GM per 30 days)oxybutynin chloride er tb24 10mg 1 MO GCoxybutynin chloride er tb24 15mg 1 MO GCoxybutynin chloride er tb24 5mg 1 MO GCoxybutynin chloride syrp 5mg/5ml 1 MO GCoxybutynin chloride tabs 5mg 1 MO GCOXYTROL PTTW 3.9MG/24HR 4 QL (8 EA per 28 days)SANCTURA XR CP24 60MG 3 QL (30 EA per 30 days) MOtolterodine tartrate tabs 1mg 2 QL (60 EA per 30 days)tolterodine tartrate tabs 2mg 2 QL (60 EA per 30 days)TOVIAZ TB24 4MG 4 QL (30 EA per 30 days)TOVIAZ TB24 8MG 4 QL (30 EA per 30 days)trospium chloride er cp24 60mg 2 QL (30 EA per 30 days)trospium chloride tabs 20mg 2 MO GCVESICARE TABS 10MG 4 QL (30 EA per 30 days)VESICARE TABS 5MG 4 QL (30 EA per 30 days)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er tb24 10mg 2 MO GCAVODART CAPS 0.5MG 4 QL (30 EA per 30 days)finasteride tabs 5mg 1 MO GCJALYN CAPS 0.5MG; 0.4MG 4 QL (30 EA per 30 days)RAPAFLO CAPS 4MG 3 QL (30 EA per 30 days) MORAPAFLO CAPS 8MG 3 QL (30 EA per 30 days) MOtamsulosin hcl caps 0.4mg 1 MO GCGenitourinary Agents, Otherbethanechol chloride tabs 10mg 2 MO GCbethanechol chloride tabs 25mg 2 MO GCbethanechol chloride tabs 50mg 2 MO GCbethanechol chloride tabs 5mg 2 MO GCcialis tabs 10mg 1 QL (6 EA per 30 days) MO GCED*cialis tabs 20mg 1 QL (6 EA per 30 days) MO GCED*PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 72

Drug NameDrugTier Requirements/LimitsDEPEN TITRATABS TABS 250MG 4ELMIRON CAPS 100MG 4viagra tabs 100mg 1 QL (6 EA per 30 days) MO GCED*viagra tabs 25mg 1 QL (6 EA per 30 days) MO GCED*viagra tabs 50mg 1 QL (6 EA per 30 days) MO GCED*Phosphate Binderscalcium acetate caps 667mg 1 MO GCeliphos tabs 667mg 2 MO GCFOSRENOL CHEW 1000MG 5FOSRENOL CHEW 500MG 5PHOSLYRA SOLN 667MG/5ML 4RENVELA PACK 0.8GM 5 QL (525 EA per 30 days)RENVELA PACK 2.4GM 5 QL (180 EA per 30 days)RENVELA TABS 800MG 4Hormonal Agents, Stimulant/ Replacement/ Modifying(Adrenal)Glucocorticoids/ Mineralocorticoidsa-hydrocort inj 100mg 2 MO GCalclometasone dipropionate crea 0.05% 1 MO GCalclometasone dipropionate oint 0.05% 1 MO GCamcinonide crea 0.1% 1 MO GCamcinonide lotn 0.1% 1 MO GCaugmented betamethasone dipropionate crea 0.05% 1 MO GCaugmented betamethasone dipropionate lotn 0.05% 1 MO GCaugmented betamethasone dipropionate oint 0.05% 1 MO GCbetamethasone dipropionate crea 0.05% 1 MO GCbetamethasone dipropionate oint 0.05% 1 MO GCbetamethasone valerate crea 0.1% 1 MO GCbetamethasone valerate lotn 0.1% 1 MO GCbetamethasone valerate oint 0.1% 1 MO GCCAPEX SHAM 0.01% 4CELESTONE SOLN 0.6MG/5ML 4clobetasol propionate e crea 0.05% 1 MO GCclobetasol propionate foam 0.05% 2 MO GCclobetasol propionate gel 0.05% 1 MO GCclobetasol propionate lotn 0.05% 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 73

Drug NameDrugTier Requirements/Limitsclobetasol propionate oint 0.05% 1 MO GCclobetasol propionate sham 0.05% 2 MO GCclobetasol propionate soln 0.05% 1 MO GCCORDRAN TAPE TAPE 4MCG/SQCM 4CORDRAN LOTN 0.05% 4cortisone acetate tabs 25mg 1 MO GCDERMA-SMOOTHE/FS BODY OIL OIL 0.01% 3 MODESONATE GEL 0.05% 4desonide crea 0.05% 1 MO GCdesonide lotn 0.05% 2 MO GCdesonide oint 0.05% 2 MO GCDESOWEN LOTN 0.05% 4desoximetasone crea 0.05% 2 MO GCdesoximetasone crea 0.25% 2 MO GCdesoximetasone gel 0.05% 2 MO GCdesoximetasone oint 0.25% 2 MO GCdexamethasone intensol conc 1mg/ml 1 MO GCdexamethasone sodium phosphate inj 4mg/ml 1 MO GCdexamethasone elix 0.5mg/5ml 1 MO GCdexamethasone tabs 0.5mg 1 MO GCdexamethasone tabs 0.75mg 1 MO GCdexamethasone tabs 1.5mg 1 MO GCdexamethasone tabs 1mg 1 MO GCdexamethasone tabs 2mg 1 MO GCdexamethasone tabs 4mg 1 MO GCdexamethasone tabs 6mg 1 MO GCdiflorasone diacetate crea 0.05% 2 MO GCdiflorasone diacetate oint 0.05% 2 MO GCfludrocortisone acetate tabs 0.1mg 1 MO GCfluocinolone acetonide crea 0.01% 1 MO GCfluocinolone acetonide crea 0.025% 1 MO GCfluocinolone acetonide oil 0.01% 2 MO GCfluocinolone acetonide oint 0.025% 1 MO GCfluocinolone acetonide soln 0.01% 1 MO GCfluocinonide-e crea 0.05% 1 MO GCfluocinonide gel 0.05% 1 MO GCfluocinonide oint 0.05% 1 MO GCfluocinonide soln 0.05% 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 74

Drug NameDrugTier Requirements/Limitsfluticasone propionate crea 0.05% 1 MO GCfluticasone propionate oint 0.005% 1 MO GChalobetasol propionate crea 0.05% 1 MO GChalobetasol propionate oint 0.05% 1 MO GCHALOG CREA 0.1% 4HALOG OINT 0.1% 4hydrocortisone valerate crea 0.2% 2 MO GChydrocortisone valerate oint 0.2% 2 MO GChydrocortisone lotn 2.5% 1 MO GChydrocortisone oint 2.5% 2 MO GChydrocortisone tabs 10mg 1 MO GChydrocortisone tabs 20mg 1 MO GChydrocortisone tabs 5mg 1 MO GCKENALOG AERS 0 4LOCOID LIPOCREAM CREA 0.1% 4methylprednisolone acetate inj 40mg/ml 1 MO GCmethylprednisolone acetate inj 80mg/ml 1 MO GCmethylprednisolone dose pack tabs 4mg 1 MO GCmethylprednisolone sodiumsuccinate inj 1gm 1 MO GCmethylprednisolone tabs 16mg 1 MO GCmethylprednisolone tabs 32mg 1 MO GCmethylprednisolone tabs 4mg 1 MO GCmethylprednisolone tabs 8mg 1 MO GCMILLIPRED TABS 5MG 3 MOmometasone furoate crea 0.1% 1 MO GCmometasone furoate oint 0.1% 1 MO GCmometasone furoate soln 0.1% 1 MO GCORAPRED ODT TBDP 30MG 3 MOPANDEL CREA 0.1% 4prednicarbate crea 0.1% 1 MO GCprednicarbate oint 0.1% 1 MO GCprednisolone sodium phosphate soln 15mg/5ml 1 MO GCprednisolone sodium phosphate soln 5mg/5ml 1 MO GCprednisone intensol conc 5mg/ml 1 MO GCprednisone soln 5mg/5ml 1 MO GCprednisone tabs 10mg 1 MO GCprednisone tabs 1mg 1 MO GCprednisone tabs 2.5mg 1 MO GCprednisone tabs 20mg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 75

Drug NameDrugTier Requirements/Limitsprednisone tabs 50mg 1 MO GCprednisone tabs 5mg 1 MO GCSOLU-CORTEF INJ 100MG 3 MOSOLU-CORTEF INJ 250MG 4triamcinolone acetonide crea 0.025% 1 MO GCtriamcinolone acetonide crea 0.1% 1 MO GCtriamcinolone acetonide crea 0.5% 1 MO GCtriamcinolone acetonide lotn 0.025% 1 MO GCtriamcinolone acetonide lotn 0.1% 1 MO GCtriamcinolone acetonide oint 0.025% 1 MO GCtriamcinolone acetonide oint 0.1% 1 MO GCtriamcinolone acetonide oint 0.5% 1 MO GCu-cort crea 1%; 10% 1 MO GCHormonal Agents, Stimulant/ Replacement/ Modifying(Pituitary)Hormonal Agents, Stimulant/ Replacement/ Modifying(Pituitary)desmopressin acetate inj 4mcg/ml 2 MO GCdesmopressin acetate soln 0.01% 2 MO GCdesmopressin acetate tabs 0.1mg 2 MO GCdesmopressin acetate tabs 0.2mg 2 MO GCGENOTROPIN MINIQUICK INJ 0.2MG 4 ST PAGENOTROPIN MINIQUICK INJ 0.4MG 5 ST PAGENOTROPIN MINIQUICK INJ 0.8MG 5 ST PAGENOTROPIN MINIQUICK INJ 1MG 5 ST PAGENOTROPIN INJ 12MG 5 ST PAGENOTROPIN INJ 5MG 5 ST PAHUMATROPE INJ 6MG 5 ST PAINCRELEX INJ 40MG/4ML 5 PANORDITROPIN FLEXPRO INJ 10MG/1.5ML 5 PANORDITROPIN FLEXPRO INJ 15MG/1.5ML 5 PANORDITROPIN FLEXPRO INJ 5MG/1.5ML 5 PANORDITROPIN NORDIFLEX PEN INJ 30MG/3ML 5 PANUTROPIN AQ PEN INJ 10MG/2ML 5 ST PAOMNITROPE INJ 5MG/1.5ML 4 PApregnyl w/diluent benzyl alcohol/nacl inj 10000unit 2 PA MO GCSAIZEN CLICK.EASY INJ 8.8MG 5 ST PATEV-TROPIN INJ 5MG 5 ST PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 76

Drug NameDrugTier Requirements/LimitsHormonal Agents, Stimulant/ Replacement/ Modifying (SexHormones/ Modifiers)Anabolic SteroidsOXANDROLONE TABS 10MG 5 PAoxandrolone tabs 2.5mg 2 PA MO GCAndrogensANDROGEL PUMP GEL 1.62% 3 PA MOANDROGEL GEL 50MG/5GM 3 PA MOANDROXY TABS 10MG 4danazol caps 100mg 2 MO GCdanazol caps 200mg 2 MO GCdanazol caps 50mg 2 MO GCMETHITEST TABS 10MG 3 MOSTRIANT MISC 30MG 4 QL (60 EA per 30 days) ST PAtestosterone cypionate inj 100mg/ml 1 PA MO GCtestosterone cypionate inj 200mg/ml 1 PA MO GCtestosterone enanthate inj 200mg/ml 1 PA MO GCTESTRED CAPS 10MG 4 PAEstrogensALORA PTTW 0.025MG/24HR 4 QL (8 EA per 30 days)ALORA PTTW 0.05MG/24HR 4 QL (8 EA per 28 days)ALORA PTTW 0.075MG/24HR 4 QL (8 EA per 28 days)ALORA PTTW 0.1MG/24HR 4 QL (8 EA per 28 days)CENESTIN TABS 0.3MG 4 PACENESTIN TABS 0.45MG 4 PACENESTIN TABS 0.625MG 4 PACENESTIN TABS 0.9MG 4 PACENESTIN TABS 1.25MG 4 PADEPO-ESTRADIOL INJ 5MG/ML 4DIVIGEL GEL 1MG/GM 4ELESTRIN GEL 0.06% 4ENJUVIA TABS 0.3MG 4 QL (30 EA per 30 days)ENJUVIA TABS 0.45MG 4 QL (30 EA per 30 days)ENJUVIA TABS 0.625MG 4 QL (30 EA per 30 days)ENJUVIA TABS 0.9MG 4 QL (30 EA per 30 days)ENJUVIA TABS 1.25MG 4 QL (60 EA per 30 days)ESTRACE CREA 0.1MG/GM 4estradiol valerate inj 10mg/ml 2 MO GCestradiol valerate inj 20mg/ml 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 77

Drug NameDrugTier Requirements/Limitsestradiol valerate inj 40mg/ml 2 MO GCestradiol ptwk 0.025mg/24hr 1 MO GCestradiol ptwk 0.05mg/24hr 1 MO GCestradiol ptwk 0.06mg/24hr 1 MO GCestradiol ptwk 0.075mg/24hr 2 MO GCestradiol ptwk 0.1mg/24hr 1 MO GCestradiol ptwk 37.5mcg/24hr 1 MO GCestradiol tabs 0.5mg 1 MO GCestradiol tabs 1mg 1 MO GCestradiol tabs 2mg 1 MO GCESTRING RING 2MG 4estropipate tabs 0.75mg 1 PA MO GCestropipate tabs 1.5mg 1 PA MO GCestropipate tabs 3mg 1 PA MO GCEVAMIST SOLN 1.53MG/SPRAY 4FEMRING RING 0.05MG/24HR 4FEMRING RING 0.1MG/24HR 4FEMTRACE TABS 0.45MG 4 QL (30 EA per 30 days)FEMTRACE TABS 0.9MG 4MENEST TABS 0.3MG 4 PAMENEST TABS 0.625MG 4 PAMENEST TABS 1.25MG 4 PAMENEST TABS 2.5MG 4 PAMENOSTAR PTWK 14MCG/24HR 4 QL (4 EA per 28 days)PREMARIN CREA 0.625MG/GM 4PREMARIN TABS 0.3MG 4 QL (30 EA per 30 days) PAPREMARIN TABS 0.45MG 4 QL (30 EA per 30 days) PAPREMARIN TABS 0.625MG 4 QL (30 EA per 30 days) PAPREMARIN TABS 0.9MG 4 QL (30 EA per 30 days) PAPREMARIN TABS 1.25MG 4 QL (60 EA per 30 days) PAVAGIFEM TABS 10MCG 4VIVELLE-DOT PTTW 0.025MG/24HR 4 QL (8 EA per 30 days)VIVELLE-DOT PTTW 0.0375MG/24HR 4 QL (8 EA per 30 days)VIVELLE-DOT PTTW 0.05MG/24HR 4 QL (8 EA per 28 days)VIVELLE-DOT PTTW 0.1MG/24HR 4 QL (8 EA per 28 days)Hormonal Agents, Stimulant/ Replacement/ Modifying(Sex Hormones/ Modifiers)amethia tabs 0; 0 2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 78

Drug NameDrugTier Requirements/Limitsamethyst tabs 20mcg; 90mcg 2 MO GCapri tabs 0.15mg; 30mcg 1 MO GCaranelle tabs 0; 0 2 MO GCaviane tabs 20mcg; 0.1mg 1 MO GCbalziva tabs 35mcg; 0.4mg 2 MO GCbriellyn tabs 35mcg; 0.4mg 2 MO GCCLIMARA PRO PTWK 0.045MG/DAY; 0.015MG/DAY 4 QL (4 EA per 28 days)COMBIPATCH PTTW 0.05MG/DAY; 0.14MG/DAY 4 QL (8 EA per 28 days)COMBIPATCH PTTW 0.05MG/DAY; 0.25MG/DAY 4 QL (8 EA per 28 days)cryselle-28 tabs 30mcg; 0.3mg 1 MO GCcyclafem 1/35 tabs 35mcg; 1mg 1 MO GCcyclafem 7/7/7 tabs 0; 0 1 MO GCemoquette tabs 0.15mg; 30mcg 2 MO GCenpresse-28 tabs 0; 0 1 MO GCestradiol/norethindrone acetate tabs 1mg; 0.5mg 2 MO GCFEMHRT LOW DOSE TABS 2.5MCG; 0.5MG 4gianvi tabs 3mg; 0.02mg 1 MO GCintrovale tabs 0.03mg; 0.15mg 2 MO GCjinteli tabs 5mcg; 1mg 1 MO GCjunel 1.5/30 tabs 30mcg; 1.5mg 1 MO GCjunel 1/20 tabs 20mcg; 1mg 1 MO GCjunel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 2 MO GCjunel fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO GCkariva tabs 0; 0 2 MO GCkelnor 1/35 tabs 35mcg; 1mg 2 MO GCleena tabs 0; 0 2 MO GClessina tabs 20mcg; 0.1mg 2 MO GClevora 0.15/30-28 tabs 30mcg; 0.15mg 2 MO GClow-ogestrel tabs 30mcg; 0.3mg 1 MO GClutera tabs 20mcg; 0.1mg 1 MO GCmarlissa tabs 0.03mg; 0.15mg 1 QL (28 EA per 28 days) MO GCmicrogestin 1.5/30 tabs 30mcg; 1.5mg 1 MO GCmicrogestin 1/20 tabs 20mcg; 1mg 1 MO GCmicrogestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 2 MO GCmicrogestin fe tabs 20mcg; 75mg; 1mg 1 MO GCmononessa tabs 35mcg; 0.25mg 1 MO GCnecon 0.5/35-28 tabs 35mcg; 0.5mg 2 MO GCnecon 1/35 tabs 35mcg; 1mg 1 MO GCnecon 7/7/7 tabs 0; 0 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 79

Drug NameDrugTier Requirements/Limitsnortrel 0.5/35 (28) tabs 35mcg; 0.5mg 2 MO GCnortrel 1/35 tabs 35mcg; 1mg 1 MO GCnortrel 1/35 tabs 35mcg; 1mg 1 MO GCnortrel 7/7/7 tabs 0; 0 1 MO GCocella tabs 3mg; 0.03mg 2 MO GCorsythia tabs 20mcg; 0.1mg 2 MO GCportia-28 tabs 0.03mg; 0.15mg 2 MO GCPREFEST TABS 0; 0 4PREMPHASE TABS 0.625MG; 5MG 4 QL (30 EA per 30 days) PAPREMPRO TABS 0.3MG; 1.5MG 4 QL (28 EA per 28 days) PAPREMPRO TABS 0.45MG; 1.5MG 4 QL (28 EA per 28 days) PAPREMPRO TABS 0.625MG; 2.5MG 4 QL (28 EA per 28 days) PAPREMPRO TABS 0.625MG; 5MG 4 QL (28 EA per 28 days) PAprevifem tabs 35mcg; 0.25mg 1 MO GCquasense tabs 0.03mg; 0.15mg 2 MO GCreclipsen tabs 0.15mg; 30mcg 1 MO GCsprintec 28 tabs 35mcg; 0.25mg 1 MO GCsronyx tabs 20mcg; 0.1mg 2 MO GCtri-legest fe tabs 0; 75mg; 1mg 2 MO GCtri-previfem tabs 0; 0 1 MO GCtri-sprintec tabs 0; 0 1 MO GCtrinessa tabs 0; 0 1 MO GCtrivora-28 tabs 0; 0 1 MO GCvelivet tabs 0; 0 2 MO GCvestura tabs 3mg; 0.02mg 1 MO GCzeosa chew 35mcg; 0; 0.4mg 2 MO GCzovia 1/35e tabs 35mcg; 1mg 2 MO GCzovia 1/50e tabs 50mcg; 1mg 2 MO GCProgestinscamila tabs 0.35mg 1 MO GCCRINONE GEL 4% 4DEPO-PROVERA INJ 400MG/ML 4DEPO-SUBQ PROVERA 104 INJ 104MG/0.65ML 4errin tabs 0.35mg 1 MO GCjolivette tabs 0.35mg 1 MO GCmedroxyprogesterone acetate inj 150mg/ml 2 MO GCmedroxyprogesterone acetate tabs 10mg 1 MO GCmedroxyprogesterone acetate tabs 2.5mg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 80

Drug NameDrugTier Requirements/Limitsmedroxyprogesterone acetate tabs 5mg 1 MO GCmegestrol acetate susp 40mg/ml 1 MO GCmegestrol acetate tabs 20mg 1 MO GCmegestrol acetate tabs 40mg 1 MO GCnext choice tabs 0.75mg 2 MO GCnora-be tabs 0.35mg 1 MO GCnorethindrone acetate tabs 5mg 2 MO GCprogesterone caps 100mg 2 MO GCprogesterone caps 200mg 2 MO GCSelective Estrogen Receptor Modifying AgentsEVISTA TABS 60MG 3 QL (30 EA per 30 days) MOHormonal Agents, Stimulant/ Replacement/ Modifying(Thyroid)Hormonal Agents, Stimulant/ Replacement/ Modifying(Thyroid)levothroid tabs 100mcg 1 MO GClevothroid tabs 112mcg 1 MO GClevothroid tabs 125mcg 1 MO GClevothroid tabs 137mcg 1 MO GClevothroid tabs 150mcg 1 MO GClevothroid tabs 175mcg 1 MO GClevothroid tabs 200mcg 1 MO GClevothroid tabs 25mcg 1 MO GClevothroid tabs 300mcg 1 MO GClevothroid tabs 50mcg 1 MO GClevothroid tabs 75mcg 1 MO GClevothroid tabs 88mcg 1 MO GClevothyroxine sodium tabs 100mcg 1 MO GClevothyroxine sodium tabs 112mcg 1 MO GClevothyroxine sodium tabs 125mcg 1 MO GClevothyroxine sodium tabs 137mcg 1 MO GClevothyroxine sodium tabs 150mcg 1 MO GClevothyroxine sodium tabs 175mcg 1 MO GClevothyroxine sodium tabs 200mcg 1 MO GClevothyroxine sodium tabs 25mcg 1 MO GClevothyroxine sodium tabs 300mcg 1 MO GClevothyroxine sodium tabs 50mcg 1 MO GClevothyroxine sodium tabs 75mcg 1 MO GClevothyroxine sodium tabs 88mcg 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 81

Drug NameDrugTier Requirements/Limitslevoxyl tabs 100mcg 1 MO GClevoxyl tabs 112mcg 1 MO GClevoxyl tabs 125mcg 1 MO GClevoxyl tabs 137mcg 1 MO GClevoxyl tabs 150mcg 1 MO GClevoxyl tabs 175mcg 1 MO GClevoxyl tabs 200mcg 1 MO GClevoxyl tabs 25mcg 1 MO GClevoxyl tabs 50mcg 1 MO GClevoxyl tabs 75mcg 1 MO GClevoxyl tabs 88mcg 1 MO GCliothyronine sodium tabs 25mcg 1 MO GCliothyronine sodium tabs 50mcg 1 MO GCliothyronine sodium tabs 5mcg 1 MO GCSYNTHROID TABS 100MCG 3 MOSYNTHROID TABS 112MCG 3 MOSYNTHROID TABS 125MCG 3 MOSYNTHROID TABS 137MCG 3 MOSYNTHROID TABS 150MCG 3 MOSYNTHROID TABS 175MCG 3 MOSYNTHROID TABS 200MCG 3 MOSYNTHROID TABS 25MCG 3 MOSYNTHROID TABS 300MCG 3 MOSYNTHROID TABS 50MCG 3 MOSYNTHROID TABS 75MCG 3 MOSYNTHROID TABS 88MCG 3 MOTIROSINT CAPS 100MCG 4TIROSINT CAPS 112MCG 4TIROSINT CAPS 125MCG 4TIROSINT CAPS 137MCG 4TIROSINT CAPS 25MCG 4TIROSINT CAPS 50MCG 4TIROSINT CAPS 75MCG 4TIROSINT CAPS 88MCG 4unithroid tabs 100mcg 1 MO GCunithroid tabs 112mcg 1 MO GCunithroid tabs 125mcg 1 MO GCunithroid tabs 150mcg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 82

Drug NameDrugTier Requirements/Limitsunithroid tabs 175mcg 1 MO GCunithroid tabs 200mcg 1 MO GCunithroid tabs 25mcg 1 MO GCunithroid tabs 300mcg 1 MO GCunithroid tabs 50mcg 1 MO GCunithroid tabs 75mcg 1 MO GCunithroid tabs 88mcg 1 MO GCHormonal Agents, Stimulant/Replacement/Modifying(Adrenal)Glucocorticoids/Mineralocorticoidsdesoximetasone oint 0.05% 2hydrocortisone butyrate crea 0.1% 2hydrocortisone butyrate oint 0.1% 2hydrocortisone butyrate soln 0.1% 2methylprednisolone sodiumsuccinate inj 125mg 1methylprednisolone sodiumsuccinate inj 40mg 1procto-pak crea 1% 1 MOproctozone-hc crea 2.5% 1 MOHormonal Agents, Stimulant/Replacement/Modifying(Pituitary)Hormonal Agents, Stimulant/Replacement/Modifying(Pituitary)ACTHAR HP INJ 80UNIT/ML 5 PAnovarel inj 10000unit 2 PAHormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)AndrogensANDRODERM PT24 2MG/24HR 3 PA MOANDRODERM PT24 4MG/24HR 3 PA MOHormonal Agents, Suppressant (Adrenal)Hormonal Agents, Suppressant (Adrenal)LYSODREN TABS 500MG 3 MOHormonal Agents, Suppressant (Parathyroid)Hormonal Agents, Suppressant (Parathyroid)SENSIPAR TABS 30MG 3 PA MOSENSIPAR TABS 60MG 3 PA MOSENSIPAR TABS 90MG 3 PA MOHormonal Agents, Suppressant (Pituitary)Hormonal Agents, Suppressant (Pituitary)PA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 83

Drug NameDrugTier Requirements/Limitscabergoline tabs 0.5mg 2 MO GCELIGARD INJ 22.5MG 4 PAELIGARD INJ 30MG 4 PAELIGARD INJ 45MG 5 PAELIGARD INJ 7.5MG 4 PAFIRMAGON INJ 120MG 5 PAleuprolide acetate inj 1mg/0.2ml 2 MO GCLUPRON DEPOT-PED INJ 11.25MG 5 PALUPRON DEPOT-PED INJ 15MG 5 PALUPRON DEPOT INJ 22.5MG 5 PALUPRON DEPOT INJ 3.75MG 5 PALUPRON DEPOT INJ 30MG 5 PALUPRON DEPOT INJ 45MG 5 PALUPRON DEPOT INJ 7.5MG 5 PAOCTREOTIDE ACETATE INJ 1000MCG/ML 5 PAoctreotide acetate inj 100mcg/ml 2 PA MO GCOCTREOTIDE ACETATE INJ 200MCG/ML 5 PAOCTREOTIDE ACETATE INJ 500MCG/ML 5 PAoctreotide acetate inj 50mcg/ml 2 PA MO GCSANDOSTATIN LAR DEPOT INJ 10MG 5 PASANDOSTATIN LAR DEPOT INJ 20MG 5 PASANDOSTATIN LAR DEPOT INJ 30MG 5 PASOMATULINE DEPOT INJ 120MG/0.5ML 5 PASOMATULINE DEPOT INJ 60MG/0.2ML 5 PASOMAVERT INJ 10MG 5 PA LASOMAVERT INJ 15MG 5 PA LASOMAVERT INJ 20MG 5 PA LASYNAREL SOLN 2MG/ML 4 PATRELSTAR DEPOT MIXJECT INJ 3.75MG 5 PATRELSTAR LA MIXJECT INJ 11.25MG 5 PAHormonal Agents, Suppressant (Sex Hormones/ Modifiers)Antiandrogensbicalutamide tabs 50mg 1 MO GCflutamide caps 125mg 1 MO GCNILANDRON TABS 150MG 4ZYTIGA TABS 250MG 5 QL (120 EA per 30 days) PAHormonal Agents, Suppressant (Sex Hormones/Modifiers)XTANDI CAPS 40MG 5 QL (120 EA per 30 days) PAPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 84

Drug NameDrugTier Requirements/LimitsHormonal Agents, Suppressant (Thyroid)Antithyroid Agentsmethimazole tabs 10mg 1 MO GCmethimazole tabs 5mg 1 MO GCpropylthiouracil tabs 50mg 1 MO GCImmunological AgentsImmune SuppressantsAFINITOR TABS 2.5MG 5 QL (90 EA per 30 days) PAAZASAN TABS 75MG 4azathioprine sodium inj 100mg 2 MO GCazathioprine tabs 50mg 1 MO GCCELLCEPT SUSR 200MG/ML 4 PACIMZIA INJ 200MG/ML 5 QL (6 EA per 28 days) PAcyclosporine modified caps 50mg 2 B/D MO GCcyclosporine modified soln 100mg/ml 2 B/D MO GCcyclosporine caps 100mg 2 B/D MO GCcyclosporine caps 25mg 2 B/D MO GCENBREL INJ 25MG/0.5ML 5 QL (600 ML per 90 days) PAENBREL INJ 25MG 5 QL (16 EA per 28 days) PAENBREL INJ 50MG/ML 5 QL (200 ML per 28 days) PAgengraf caps 100mg 2 B/D MO GCgengraf caps 25mg 2 B/D MO GCgengraf soln 100mg/ml 2 B/D MO GCHUMIRA INJ 20MG/0.4ML 5 QL (6 EA per 28 days) PAHUMIRA INJ 40MG/0.8ML 5 QL (6 EA per 28 days) PAKINERET INJ 100MG/0.67ML 5 QL (18.8 ML per 28 days) PAmercaptopurine tabs 50mg 1 MO GCmethotrexate sodium inj 25mg/ml 1 MO GCmethotrexate tabs 2.5mg 1 MO GCmycophenolate mofetil caps 250mg 2 PA MO GCmycophenolate mofetil tabs 500mg 2 PA MO GCMYFORTIC TBEC 180MG 4 B/DMYFORTIC TBEC 360MG 5 B/DORENCIA INJ 125MG/1ML 5 PAORENCIA INJ 250MG 5 PARAPAMUNE SOLN 1MG/ML 5 B/DRAPAMUNE TABS 0.5MG 4 B/DRAPAMUNE TABS 1MG 5 B/DRAPAMUNE TABS 2MG 5 B/DPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 85

Drug NameDrugTier Requirements/LimitsREMICADE INJ 100MG 5 PARHEUMATREX TABS 2.5MG 4SIMPONI INJ 50MG/0.5ML 5 QL (1 ML per 30 days) PAtacrolimus caps 0.5mg 2 B/D MO GCtacrolimus caps 1mg 2 PA MO GCTACROLIMUS CAPS 5MG 5 PATREXALL TABS 10MG 4TREXALL TABS 15MG 4ZORTRESS TABS 0.5MG 5 PAZORTRESS TABS 0.75MG 5 PAImmunizing Agents, PassiveCARIMUNE NANOFILTERED INJ 3GM 5 B/DGAMASTAN S/D INJ 0 4GAMMAGARD LIQUID INJ 0 5 B/DImmunomodulatorsACTEMRA INJ 200MG/10ML 5 PAACTIMMUNE INJ 2000000UNIT/0.5ML 5 PA LAARCALYST INJ 220MG 5leflunomide tabs 10mg 1 MO GCleflunomide tabs 20mg 1 MO GCRIDAURA CAPS 3MG 4XELJANZ TABS 5MG 5 QL (60 EA per 30 days) PA MOVaccinesACTHIB INJ 0 3 MOADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML 3 MOBOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 45LF/0.5MLBOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 45LF/0.5MLCERVARIX INJ 0 4COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML 4DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML4DECAVAC INJ 2LFU; 5LFU 3 MOENGERIX-B INJ 10MCG/0.5ML 3 B/D MOENGERIX-B INJ 20MCG/ML 3 B/D MOGARDASIL INJ 0 4HAVRIX INJ 1440ELU/ML 3 MOHAVRIX INJ 720ELU/0.5ML 3 MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 86

Drug NameDrugTier Requirements/LimitsIMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML 4INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 410LFU/0.5MLIPOL INACTIVATED IPV INJ 0 4IXIARO INJ 0 4M-M-R II W/DILUENT 10 DOSE INJ 0; 0; 0 4MENACTRA INJ 0 4MENOMUNE-A/C/Y/W-135 INJ 0 4MENVEO INJ 0 4PEDVAX HIB INJ 0 4PROQUAD INJ 0; 0; 0; 0 4RABAVERT INJ 0 4RECOMBIVAX HB INJ 10MCG/ML 4 B/DRECOMBIVAX HB INJ 40MCG/ML 4 B/DROTATEQ SUSP 0 4TETANUS TOXOID ADSORBED INJ 5LFU 3TETANUS/DIPHTHERIA TOXOIDS-ADSORBED 3 MOADULT INJ 2LF/0.5ML; 2LF/0.5MLTWINRIX INJ 720ELU/ML; 20MCG/ML 4TYPHIM VI INJ 25MCG/0.5ML 4VAQTA INJ 25UNIT/0.5ML 4VARIVAX INJ 1350PFU/0.5ML 4YF-VAX INJ 0 4ZOSTAVAX INJ 19400UNT/0.65ML 4 QL (1 EA per 365 days)Inflammatory Bowel Disease AgentsAminosalicylatesAPRISO CP24 0.375GM 3 MOASACOL HD TBEC 800MG 4ASACOL TBEC 400MG 4balsalazide disodium caps 750mg 2 MO GCCANASA SUPP 1000MG 4DIPENTUM CAPS 250MG 4LIALDA TBEC 1.2GM 4mesalamine kit 4gm 2 MO GCPENTASA CPCR 250MG 4PENTASA CPCR 500MG 4Glucocorticoidscolocort enem 100mg/60ml 2 MO GChydrocortisone enem 100mg/60ml 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 87

Drug NameDrugTier Requirements/Limitsproctocream hc crea 2.5% 1 MO GCSulfonamidessulfasalazine tabs 500mg 1 MO GCsulfazine ec tbec 500mg 1 MO GCMetabolic Bone Disease AgentsMetabolic Bone Disease AgentsACTONEL TABS 150MG 4 QL (1 EA per 28 days) STACTONEL TABS 30MG 4 QL (30 EA per 30 days) STACTONEL TABS 35MG 4 QL (4 EA per 30 days) STACTONEL TABS 5MG 4 QL (30 EA per 30 days) STalendronate sodium tabs 10mg 1 MO GCalendronate sodium tabs 35mg 1 MO GCalendronate sodium tabs 40mg 1 MO GCalendronate sodium tabs 5mg 1 MO GCalendronate sodium tabs 70mg 1 MO GCATELVIA TBEC 35MG 4 QL (4 EA per 28 days) STcalcitonin-salmon soln 200unit/act 2 MO GCcalcitriol caps 0.25mcg 2 B/D MO GCcalcitriol caps 0.5mcg 2 B/D MO GCetidronate disodium tabs 400mg 2 MO GCFORTEO INJ 600MCG/2.4ML 5 QL (2.4 ML per 30 days) PAFORTICAL SOLN 200UNIT/ACT 4FOSAMAX PLUS D TABS 70MG; 2800UNIT 4 QL (4 EA per 28 days) STFOSAMAX PLUS D TABS 70MG; 5600UNIT 4 QL (4 EA per 28 days) STHECTOROL CAPS 0.5MCG 4 ST B/DHECTOROL CAPS 1MCG 4 ST B/DHECTOROL CAPS 2.5MCG 4 ST B/Dibandronate sodium tabs 150mg 2 QL (1 EA per 30 days) MO GCPAMIDRONATE DISODIUM INJ 6MG/ML 4 B/DPROLIA INJ 60MG/ML 4 QL (1 ML per 180 days) PARECLAST INJ 5MG/100ML 4 B/DXGEVA INJ 120MG/1.7ML 5 QL (5.1 ML per 90 days) PAZEMPLAR CAPS 1MCG 4 B/DZEMPLAR CAPS 2MCG 4 B/DZEMPLAR INJ 2MCG/ML 4 B/DZOMETA INJ 4MG/5ML 5 B/DOphthalmic AgentsOphthalmic Agents, OtherPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 88

Drug NameDrugTier Requirements/LimitsRESTASIS EMUL 0.05% 4Ophthalmic Agentsbacitracin/polymyxin b oint 500unit/gm; 10000unit/gm 1 MO GCBLEPHAMIDE S.O.P. OINT 0.2%; 10% 4BLEPHAMIDE SUSP 0.2%; 10% 4neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/gm; 1 MO GC10000unit/gmneomycin/polymyxin/bacitracin/hydrocortisone oint 2 MO GC400unit/gm; 1%; 0.5%; 10000unit/gmneomycin/polymyxin/dexamethasone oint 0.1%; 1 MO GC3.5mg/gm; 10000unit/gmneomycin/polymyxin/dexamethasone susp 0.1%; 1 MO GC3.5mg/ml; 10000unit/mlneomycin/polymyxin/gramicidin soln 0.025mg/ml; 1 MO GC1.75mg/ml; 10000unit/mlneomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml; 2 MO GC10000unit/mlPRED-G SUSP 0.3%; 1% 3 MOsulfacetamide sodium/prednisolone sodium phosphate 1 MO GCsoln 0.23%; 10%sulfacetamide sodium oint 10% 1 MO GCTOBRADEX ST SUSP 0.05%; 0.3% 4tobramycin/dexamethasone susp 0.1%; 0.3% 2 MO GCtrimethoprim sulfate/polymyxin b sulfate soln 1 MO GC10000unit/ml; 0.1%ZYLET SUSP 0.5%; 0.3% 4Ophthalmic Anti-allergy AgentsALOCRIL SOLN 2% 4ALOMIDE SOLN 0.1% 4azelastine hcl soln 0.05% 2 MO GCBEPREVE SOLN 1.5% 4cromolyn sodium soln 4% 1 MO GCELESTAT SOLN 0.05% 4 STEMADINE SOLN 0.05% 4epinastine hcl soln 0.05% 2 MO GCLASTACAFT SOLN 0.25% 4PATADAY SOLN 0.2% 4PATANOL SOLN 0.1% 4Ophthalmic Anti-inflammatoriesPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 89

Drug NameDrugTier Requirements/LimitsACUVAIL SOLN 0.45% 4ALREX SUSP 0.2% 4BROMDAY SOLN 0.09% 4bromfenac soln 0.09% 2 MO GCdexamethasone sodium phosphate soln 0.1% 1 MO GCdiclofenac sodium soln 0.1% 1 MO GCDUREZOL EMUL 0.05% 4FLAREX SUSP 0.1% 3 MOflurbiprofen sodium soln 0.03% 1 MO GCFML FORTE SUSP 0.25% 3 MOFML OINT 0.1% 3 MOketorolac tromethamine soln 0.4% 1 MO GCketorolac tromethamine soln 0.5% 1 MO GCLOTEMAX GEL 0.5% 4LOTEMAX OINT 0.5% 4LOTEMAX SUSP 0.5% 4MAXIDEX SUSP 0.1% 3 MOMILLIPRED SOLN 10MG/5ML 4NEVANAC SUSP 0.1% 4ORAPRED ODT TBDP 15MG 4PRED MILD SUSP 0.12% 3 MOprednisolone acetate susp 1% 1 MO GCprednisolone sodium phosphate soln 1% 1 MO GCVEXOL SUSP 1% 3 MOOphthalmic Antiglaucoma AgentsALPHAGAN P SOLN 0.1% 4apraclonidine soln 0.5% 2 MO GCAZOPT SUSP 1% 4betaxolol hcl soln 0.5% 2 MO GCBETIMOL SOLN 0.25% 4BETIMOL SOLN 0.5% 4BETOPTIC-S SUSP 0.25% 4brimonidine tartrate soln 0.15% 1 MO GCbrimonidine tartrate soln 0.2% 1 MO GCcarteolol hcl soln 1% 1 MO GCCOMBIGAN SOLN 0.2%; 0.5% 4dorzolamide hcl/timolol maleate soln 22.3mg/ml;6.8mg/ml2 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 90

Drug NameDrugTier Requirements/Limitsdorzolamide hcl soln 2% 1 MO GCISTALOL SOLN 0.5% 4levobunolol hcl soln 0.5% 1 MO GCmetipranolol soln 0.3% 1 MO GCPHOSPHOLINE IODIDE SOLR 0.125% 4PILOPINE HS GEL 4% 4timolol maleate ophthalmic gel forming solg 0.25% 1 MO GCtimolol maleate ophthalmic gel forming solg 0.5% 1 MO GCtimolol maleate soln 0.25% 1 MO GCtimolol maleate soln 0.5% 1 MO GCOphthalmic Prostaglandin and Prostamide Analogslatanoprost soln 0.005% 1 MO GCLUMIGAN SOLN 0.01% 3 PA MOLUMIGAN SOLN 0.03% 3 MOTRAVATAN Z SOLN 0.004% 3 MOOtic AgentsOtic Agentsacetasol hc soln 2%; 1% 2 MO GCCIPRO HC SUSP 0.2%; 1% 4CIPRODEX SUSP 0.3%; 0.1% 4COLY-MYCIN S SUSP 3MG/ML; 10MG/ML; 3.3MG/ML; 40.5MG/MLCORTISPORIN-TC SUSP 3MG/ML; 10MG/ML; 43.3MG/ML; 0.5MG/MLDERMOTIC OIL 0.01% 4neomycin/polymyxin/hc soln 1%; 3.5mg/ml; 10000unit/ml1 MO GCneomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml; 1 MO GC10000unit/mlRespiratory Tract AgentsAnti-inflammatories, Inhaled CorticosteroidsALVESCO AERS 160MCG/ACT 4ALVESCO AERS 80MCG/ACT 4ASMANEX 120 METERED DOSES AEPB 220MCG/INH 4ASMANEX 30 METERED DOSES AEPB 110MCG/INH 4budesonide susp 0.25mg/2ml 2 B/D MO GCbudesonide susp 0.5mg/2ml 2 B/D MO GCFLOVENT DISKUS AEPB 100MCG/BLIST 4FLOVENT DISKUS AEPB 250MCG/BLIST 4FLOVENT DISKUS AEPB 50MCG/BLIST 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 91

Drug NameDrugTier Requirements/LimitsFLOVENT HFA AERO 110MCG/ACT 4FLOVENT HFA AERO 220MCG/ACT 4FLOVENT HFA AERO 44MCG/ACT 4flunisolide soln 0.025% 2 MO GCfluticasone propionate susp 50mcg/act 2 MO GCNASONEX SUSP 50MCG/ACT 3 MOPULMICORT FLEXHALER AEPB 180MCG/ACT 4PULMICORT FLEXHALER AEPB 90MCG/ACT 4QVAR AERS 40MCG/ACT 4QVAR AERS 80MCG/ACT 4RHINOCORT AQUA SUSP 32MCG/ACT 4 STtriamcinolone acetonide inha 55mcg/act 2 MO GCVERAMYST SUSP 27.5MCG/SPRAY 4 STAntihistaminesASTEPRO SOLN 0.15% 3 MOazelastine hcl soln 137mcg/spray 2 MO GCcarbinoxamine maleate liqd 4mg/5ml 1 MO GCcarbinoxamine maleate tabs 4mg 1 MO GCcetirizine hcl syrp 5mg/5ml 1 MO GCcyproheptadine hcl syrp 2mg/5ml 1 PA MO GCcyproheptadine hcl tabs 4mg 1 PA MO GCdesloratadine tabs 5mg 2levocetirizine dihydrochloride tabs 5mg 1 MO GCPATANASE SOLN 0.6% 4Antileukotrienesmontelukast sodium chew 4mg 2 QL (30 EA per 30 days)montelukast sodium chew 5mg 2 QL (30 EA per 30 days)montelukast sodium pack 4mg 2 QL (30 EA per 30 days)montelukast sodium tabs 10mg 2 QL (30 EA per 30 days)SINGULAIR CHEW 4MG 3 QL (30 EA per 30 days) MOSINGULAIR CHEW 5MG 3 QL (30 EA per 30 days) MOSINGULAIR PACK 4MG 3 QL (30 EA per 30 days) MOSINGULAIR TABS 10MG 3 QL (30 EA per 30 days) MOzafirlukast tabs 10mg 2 MO GCzafirlukast tabs 20mg 2 MO GCZYFLO CR TB12 600MG 4 QL (120 EA per 30 days)Bronchodilators, AnticholinergicATROVENT HFA AERS 17MCG/ACT 4PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 92

Drug NameDrugTier Requirements/LimitsCOMBIVENT RESPIMAT AERS 100MCG/ACT; 4 QL (8 GM per 30 days) MO20MCG/ACTipratropium bromide soln 0.02% 1 B/D MO GCipratropium bromide soln 0.03% 1 MO GCipratropium bromide soln 0.06% 1 MO GCSPIRIVA HANDIHALER CAPS 18MCG 3 MOTUDORZA PRESSAIR AEPB 400MCG/ACT 4 QL (60 EA per 30 days) MOBronchodilators, Phosphodiesterase Inhibitors(Xanthines)aminophylline inj 25mg/ml 1 MO GCELIXOPHYLLIN ELIX 80MG/15ML 4LUFYLLIN TABS 200MG 4LUFYLLIN TABS 400MG 4theophylline cr tb12 100mg 1 MO GCtheophylline cr tb12 200mg 1 MO GCtheophylline er tb12 300mg 1 MO GCtheophylline er tb12 450mg 1 MO GCtheophylline er tb24 400mg 1 MO GCtheophylline er tb24 600mg 1 MO GCBronchodilators, Sympathomimeticalbuterol sulfate er tb12 4mg 2 MO GCalbuterol sulfate er tb12 8mg 1 MO GCalbuterol sulfate nebu 0.083% 1 B/D MO GCalbuterol sulfate nebu 0.5% 1 B/D MO GCalbuterol sulfate nebu 0.63mg/3ml 2 B/D MO GCalbuterol sulfate nebu 1.25mg/3ml 2 B/D MO GCalbuterol sulfate syrp 2mg/5ml 1 MO GCalbuterol sulfate tabs 2mg 1 MO GCalbuterol sulfate tabs 4mg 1 MO GCARCAPTA NEOHALER CAPS 75MCG 4BROVANA NEBU 15MCG/2ML 4 B/DDULERA AERO 5MCG/ACT; 100MCG/ACT 4 QL (13 GM per 25 days)DULERA AERO 5MCG/ACT; 200MCG/ACT 4 QL (13 GM per 25 days)epinephrine hcl inj 0.1mg/ml 1 MO GCEPIPEN 2-PAK INJ 0.3MG/0.3ML 4 QL (2 EA per 30 days)EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML 4 QL (2 EA per 30 days)FORADIL AEROLIZER CAPS 12MCG 4 QL (60 EA per 30 days)levalbuterol nebu 1.25mg/0.5ml 2 B/D MO GCMAXAIR AUTOHALER AERB 200MCG/INH 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 93

Drug NameDrugTier Requirements/Limitsmetaproterenol sulfate syrp 10mg/5ml 1 MO GCPERFOROMIST NEBU 20MCG/2ML 4 B/DPROAIR HFA AERS 108MCG/ACT 4PROVENTIL HFA AERS 108MCG/ACT 4SEREVENT DISKUS AEPB 50MCG/DOSE 4 QL (60 EA per 30 days)terbutaline sulfate inj 1mg/ml 1 MO GCterbutaline sulfate tabs 2.5mg 1 MO GCterbutaline sulfate tabs 5mg 1 MO GCTWINJECT INJ 0.3MG/0.3ML 4 QL (4 EA per 30 days)VENTOLIN HFA AERS 108MCG/ACT 4XOPENEX HFA AERO 45MCG/ACT 4Mast Cell Stabilizerscromolyn sodium nebu 20mg/2ml 2 B/D MO GCPulmonary AntihypertensivesADCIRCA TABS 20MG 5 QL (60 EA per 30 days) PALETAIRIS TABS 10MG 5 QL (30 EA per 30 days) PA LALETAIRIS TABS 5MG 5 QL (30 EA per 30 days) PA LAREVATIO TABS 20MG 5 QL (90 EA per 30 days) PASILDENAFIL CITRATE TABS 20MG 5 QL (90 EA per 30 days) PATRACLEER TABS 125MG 5 QL (60 EA per 30 days) PA LATRACLEER TABS 62.5MG 5 QL (120 EA per 30 days) PA LAVENTAVIS SOLN 10MCG/ML 5 PARespiratory Tract Agents, Otheracetylcysteine soln 10% 2 B/D MO GCacetylcysteine soln 20% 2 B/D MO GCARALAST NP INJ 400MG 5 PA LAhydrocodone bitartrate/homatropine methylbromide syrp 1 QL (180 ML per 30 days) MO GC1.5mg/5ml; 5mg/5mlED*KALYDECO TABS 150MG 5 PAPROLASTIN-C INJ 1000MG 5 PA LApromethazine vc/codeine syrp 10mg/5ml; 5mg/5ml;6.25mg/5ml1 QL (180 ML per 30 days) MO GCED*promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml 1 QL (180 ML per 30 days) MO GCED*promethazine/dextromethorphan syrp 15mg/5ml;6.25mg/5ml1 QL (180 ML per 30 days) MO GCED*TYZINE PEDIATRIC NASAL DROPS SOLN 0.05% 3 MOTYZINE SOLN 0.1% 3 MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 94

Drug NameDrugTier Requirements/LimitsZEMAIRA INJ 1000MG 5 PA LARespiratory Tract AgentsADVAIR DISKUS AEPB 100MCG/DOSE;4 QL (60 EA per 30 days)50MCG/DOSEADVAIR DISKUS AEPB 250MCG/DOSE;4 QL (60 EA per 30 days)50MCG/DOSEADVAIR DISKUS AEPB 500MCG/DOSE;4 QL (60 EA per 30 days)50MCG/DOSEADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT 4 QL (60 GM per 30 days)ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT 4 QL (60 GM per 30 days)ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT 4 QL (60 GM per 30 days)COMBIVENT AERO 103MCG/ACT; 18MCG/ACT 4DALIRESP TABS 500MCG 4ipratropium bromide/albuterol sulfate soln 2.5mg/3ml; 2 B/D MO GC0.5mg/3mlpromethazine vc syrp 5mg/5ml; 6.25mg/5ml 1 PA MO GCPULMOZYME SOLN 1MG/ML 5 PASYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 3 QL (11 GM per 30 days) MOSYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 3 QL (11 GM per 30 days) MOXOLAIR INJ 150MG 5 PA LASkeletal Muscle RelaxantsSkeletal Muscle Relaxantscarisoprodol tabs 350mg 2 PA MO GCchlorzoxazone tabs 500mg 2 PA MO GCcyclobenzaprine hcl er cp24 15mg 2 PA MO GCcyclobenzaprine hcl er cp24 30mg 2 PA MO GCcyclobenzaprine hcl tabs 10mg 2 PA MO GCcyclobenzaprine hcl tabs 5mg 2 PA MO GCmethocarbamol tabs 500mg 2 PA MO GCmethocarbamol tabs 750mg 2 PA MO GCorphenadrine citrate er tb12 100mg 2 PA MO GCorphenadrine citrate inj 30mg/ml 2 PA MO GCsoma tabs 250mg 2 MO GCtizanidine hcl caps 2mg 2 MO GCtizanidine hcl caps 4mg 2 MO GCtizanidine hcl caps 6mg 2 MO GCSleep Disorder AgentsGABA Receptor ModulatorsLUNESTA TABS 1MG 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 95

Drug NameDrugTier Requirements/LimitsLUNESTA TABS 2MG 4 QL (30 EA per 30 days) STLUNESTA TABS 3MG 4 QL (30 EA per 30 days) STzaleplon caps 10mg 1 QL (30 EA per 30 days) MO GCzaleplon caps 5mg 1 QL (30 EA per 30 days) MO GCzolpidem tartrate er tbcr 12.5mg 2 QL (30 EA per 30 days) MO GCzolpidem tartrate er tbcr 6.25mg 2 QL (30 EA per 30 days) MO GCzolpidem tartrate tabs 10mg 1 QL (30 EA per 30 days) MO GCzolpidem tartrate tabs 5mg 1 QL (30 EA per 30 days) MO GCSleep Disorders, Othermodafinil tabs 100mg 2 PA MOmodafinil tabs 200mg 2 PA MONUVIGIL TABS 150MG 4 QL (30 EA per 30 days) PANUVIGIL TABS 250MG 4 QL (30 EA per 30 days) PANUVIGIL TABS 50MG 4 QL (30 EA per 30 days) PAROZEREM TABS 8MG 4 QL (30 EA per 30 days) STXYREM SOLN 500MG/ML 5 QL (540 ML per 30 days) PA LATherapeutic Nutrients/ Minerals/ ElectrolytesElectrolyte/ Mineral ModifiersEXJADE TBSO 250MG 5 PA LAEXJADE TBSO 500MG 5 PA LAkionex powd 0 2 MO GCSAMSCA TABS 15MG 5 PAElectrolyte/ Mineral Replacementklor-con 10 tbcr 10meq 1 MO GCklor-con 8 tbcr 8meq 1 MO GCKLOR-CON M15 TBCR 15MEQ 3 MOklor-con m20 tbcr 20meq 1 MO GCOSMOPREP TABS 0.398GM; 1.102GM 4PLASMA-LYTE-148 INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 43MEQ/L; 5MEQ/L; 140MEQ/Lpotassium chloride 0.15% /nacl 0.45% viaflex inj 1 MO GC20meq/l; 0.45%potassium chloride 0.15% nacl 0.9% inj 20meq/l; 0.9% 1 MO GCpotassium chloride er cpcr 10meq 1 MO GCpotassium chloride er cpcr 8meq 1 MO GCpotassium chloride er tbcr 10meq 1 MO GCpotassium chloride er tbcr 20meq 1 MO GCpotassium chloride inj 0.4meq/ml 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 96

Drug NameDrugTier Requirements/Limitspotassium chloride inj 10meq/100ml 1 MO GCpotassium chloride inj 2meq/ml 1 MO GCpotassium chloride inj 30meq/100ml 1 MO GCsodium chloride 0.45% viaflex inj 0.45% 1 MO GCsodium chloride 0.9% soln 0.9% 1 MO GCsodium chloride inj 0.9% 1 MO GCSUPREP BOWEL PREP SOLN 1.6GM/180ML; 43.13GM/180ML; 17.5GM/180MLTherapeutic Nutrients/ Minerals/ ElectrolytesAMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 3 B/D MO713MG/100ML; 490MG/100ML; 517MG/100ML;350MG/100ML; 210MG/100ML; 462MG/100ML;700MG/100ML; 735MG/100ML; 120MG/100ML;209MG/100ML; 505MG/100ML; 371MG/100ML;31.3MEQ/L; 280MG/100ML; 140MG/100ML;189MG/100ML; 350MG/100MLAMINOSYN II INJ 61.1MEQ/L; 844MG/100ML; 3 B/D MO865MG/100ML; 595MG/100ML; 627MG/100ML;425MG/100ML; 255MG/100ML; 561MG/100ML;850MG/100ML; 893MG/100ML; 146MG/100ML;253MG/100ML; 614MG/100ML; 450MG/100ML;33.3MEQ/L; 340MG/100ML; 170MG/100ML;230MG/100ML; 425MG/100MLAMINOSYN M INJ 65MEQ/L; 448MG/100ML; 3 B/D MO343MG/100ML; 40MEQ/L; 448MG/100ML;105MG/100ML; 252MG/100ML; 329MG/100ML;252MG/100ML; 3MEQ/L; 140MG/100ML;154MG/100ML; 3.5MMOLE/L; 13MEQ/L;300MG/100ML; 147MG/100ML; 40MEQ/L;182MG/100ML; 56MG/100ML; 31MG/100ML;280MG/100MLAMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML;507MG/100ML; 4MEQ/100ML; 660MG/100ML;154MG/100ML; 789MG/100ML; 1576MG/100ML;265MG/100ML; 206MG/100ML; 1.12GM/100ML;228MG/100ML; 448MG/100ML; 221MG/100ML;272MG/100ML; 88MG/100ML; 33MG/100ML;789MG/100ML3 B/D MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 97

Drug NameAMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML;861MG/100ML; 370MG/100ML; 576MG/100ML;270MG/100ML; 220MG/100ML; 534MG/100ML;831MG/100ML; 475MG/100ML; 125MG/100ML;10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L;347MG/100ML; 50MG/100ML; 360MG/100ML;125MG/100ML; 44MG/100ML; 452MG/100MLAMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;1227MG/100ML; 527MG/100ML; 820MG/100ML;385MG/100ML; 312MG/100ML; 760MG/100ML;1200MG/100ML; 677MG/100ML; 180MG/100ML;427MG/100ML; 812MG/100ML; 495MG/100ML;3.4MEQ/L; 70MG/100ML; 512MG/100ML;180MG/100ML; 44MG/100ML; 673MG/100MLCLINIMIX 2.75%/DEXTROSE 5% INJ 24MEQ/1000ML;570MG/100ML; 316MG/100ML; 11MEQ/1000ML;5GM/100ML; 283MG/100ML; 132MG/100ML;165MG/100ML; 201MG/100ML; 159MG/100ML;110MG/100ML; 154MG/100ML; 187MG/100ML;138MG/100ML; 116MG/100ML; 50MG/100ML;11MG/100ML; 160MG/100MLCLINIMIX 4.25%/DEXTROSE 10% INJ 37MEQ/L;880MG/100ML; 489MG/100ML; 17MEQ/L;10GM/100ML; 438MG/100ML; 204MG/100ML;255MG/100ML; 311MG/100ML; 247MG/100ML;170MG/100ML; 238MG/100ML; 289MG/100ML;213MG/100ML; 179MG/100ML; 77MG/100ML;17MG/100ML; 247MG/100MLCLINIMIX 4.25%/DEXTROSE 20% INJ 37MEQ/L;880MG/100ML; 489MG/100ML; 17MEQ/L;20GM/100ML; 438MG/100ML; 204MG/100ML;255MG/100ML; 311MG/100ML; 247MG/100ML;170MG/100ML; 238MG/100ML; 289MG/100ML;213MG/100ML; 179MG/100ML; 77MG/100ML;17MG/100ML; 247MG/100MLDrugTier Requirements/Limits3 B/D MO3 B/D MO3 B/D MO3 B/D MO3 B/D MOPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 98

Drug NameDrugTier Requirements/LimitsCLINIMIX 4.25%/DEXTROSE 25% INJ 37MEQ/L; 3 B/D MO880MG/100ML; 489MG/100ML; 17MEQ/L;25GM/100ML; 438MG/100ML; 204MG/100ML;255MG/100ML; 311MG/100ML; 247MG/100ML;170MG/100ML; 238MG/100ML; 289MG/100ML;213MG/100ML; 179MG/100ML; 77MG/100ML;17MG/100ML; 247MG/100MLCLINIMIX 4.25%/DEXTROSE 5% INJ 37MEQ/L; 3 B/D MO880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML;438MG/100ML; 204MG/100ML; 255MG/100ML;311MG/100ML; 247MG/100ML; 170MG/100ML;238MG/100ML; 289MG/100ML; 213MG/100ML;179MG/100ML; 77MG/100ML; 17MG/100ML;247MG/100MLCLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML; 3 B/D MO1035MG/100ML; 575MG/100ML; 20MEQ/1000ML;15GM/100ML; 515MG/100ML; 240MG/100ML;300MG/100ML; 365MG/100ML; 290MG/100ML;200MG/100ML; 280MG/100ML; 340MG/100ML;250MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L; 3 B/D MO1035MG/100ML; 575MG/100ML; 20MEQ/L;20GM/100ML; 515MG/100ML; 240MG/100ML;300MG/100ML; 365MG/100ML; 290MG/100ML;200MG/100ML; 280MG/100ML; 340MG/100ML;250MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L;1035MG/100ML; 575MG/100ML; 20MEQ/L;25GM/100ML; 515MG/100ML; 240MG/100ML;300MG/100ML; 365MG/100ML; 290MG/100ML;200MG/100ML; 280MG/100ML; 340MG/100ML;250MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100ML3 B/D MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 99

Drug NameDrugTier Requirements/LimitsCLINIMIX E 2.75%/DEXTROSE 10% INJ3 B/D MO570MG/100ML; 316MG/100ML; 33MG/100ML;10GM/100ML; 132MG/100ML; 165MG/100ML;201MG/100ML; 159MG/100ML; 51MG/100ML;110MG/100ML; 454MG/100ML; 154MG/100ML;261MG/100ML; 187MG/100ML; 138MG/100ML;217MG/100ML; 112MG/100ML; 116MG/100ML;50MG/100ML; 11MG/100ML; 160MG/100MLCLINIMIX E 2.75%/DEXTROSE 5% INJ 570MG/100ML; 3 B/D MO316MG/100ML; 33MG/100ML; 5GM/100ML;132MG/100ML; 165MG/100ML; 201MG/100ML;159MG/100ML; 51MG/100ML; 110MG/100ML;454MG/100ML; 154MG/100ML; 261MG/100ML;187MG/100ML; 138MG/100ML; 217MG/100ML;112MG/100ML; 116MG/100ML; 50MG/100ML;11MG/100ML; 160MG/100MLCLINIMIX E 4.25%/DEXTROSE 25% INJ3 B/D MO880MG/100ML; 489MG/100ML; 33MG/100ML;25GM/100ML; 204MG/100ML; 255MG/100ML;311MG/100ML; 247MG/100ML; 51MG/100ML;170MG/100ML; 702MG/100ML; 238MG/100ML;261MG/100ML; 289MG/100ML; 213MG/100ML;297MG/100ML; 77MG/100ML; 179MG/100ML;77MG/100ML; 17MG/100ML; 247MG/100MLCLINIMIX E 4.25%/DEXTROSE 5% INJ 880MG/100ML; 3 B/D MO489MG/100ML; 33MG/100ML; 5GM/100ML;204MG/100ML; 255MG/100ML; 311MG/100ML;247MG/100ML; 51MG/100ML; 170MG/100ML;702MG/100ML; 238MG/100ML; 261MG/100ML;289MG/100ML; 213MG/100ML; 297MG/100ML;77MG/100ML; 179MG/100ML; 77MG/100ML;17MG/100ML; 247MG/100MLPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 100

Drug NameDrugTier Requirements/LimitsCLINIMIX E 5%/DEXTROSE 15% INJ 1035MG/100ML; 3 B/D MO575MG/100ML; 33MG/100ML; 15GM/100ML;240MG/100ML; 300MG/100ML; 365MG/100ML;290MG/100ML; 51MG/100ML; 200MG/100ML;826MG/100ML; 280MG/100ML; 261MG/100ML;340MG/100ML; 250MG/100ML; 340MG/100ML;59MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINIMIX E 5%/DEXTROSE 20% INJ 1035MG/100ML; 3 B/D MO575MG/100ML; 33MG/100ML; 20GM/100ML;240MG/100ML; 300MG/100ML; 365MG/100ML;290MG/100ML; 51MG/100ML; 200MG/100ML;826MG/100ML; 280MG/100ML; 261MG/100ML;340MG/100ML; 250MG/100ML; 340MG/100ML;59MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINIMIX E 5%/DEXTROSE 25% INJ 1035MG/100ML; 3 B/D MO575MG/100ML; 33MG/100ML; 25GM/100ML;240MG/100ML; 300MG/100ML; 365MG/100ML;290MG/100ML; 51MG/100ML; 200MG/100ML;826MG/100ML; 280MG/100ML; 261MG/100ML;340MG/100ML; 250MG/100ML; 340MG/100ML;59MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINISOL SF 15% INJ 151MEQ/L; 2170MG/100ML; 4 B/D1470MG/100ML; 434MG/100ML; 749MG/100ML;1040MG/100ML; 894MG/100ML; 749MG/100ML;1040MG/100ML; 1180MG/100ML; 749MG/100ML;1040MG/100ML; 894MG/100ML; 592MG/100ML;749MG/100ML; 250MG/100ML; 39MG/100ML;960MG/100MLdextrose 10% flex container inj 10% 1 MO GCdextrose 10%/nacl 0.2% inj 10%; 0.2% 1 MO GCdextrose 2.5%/sodium chloride 0.45% inj 2.5%; 0.45% 1 MO GCDEXTROSE 5%/LACTATED RINGERS INJ 2.7MEQ/L; 4109MEQ/L; 5%; 28MEQ/L; 4MEQ/L; 130MEQ/Ldextrose 5%/nacl 0.2% inj 5%; 0.2% 1 MO GCdextrose 5%/nacl 0.33% inj 5%; 0.33% 1 MO GCdextrose 5%/nacl 0.45% inj 5%; 0.45% 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 of Coverage for more information aboutthis coverage. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 101

Drug NameDrugTier Requirements/Limitsdextrose 5%/nacl 0.9% inj 5%; 0.9% 1 MO GCdextrose 5%/potassium chloride 0.15% inj 5%; 20meq/l 1 MO GCdextrose 5% inj 5% 1 MO GCFREAMINE III 3% INJ 44MEQ/L; 210MG/100ML; 3 B/D MO290MG/100ML; 41MEQ/L; 20MG/100ML;420MG/100ML; 85MG/100ML; 210MG/100ML;270MG/100ML; 220MG/100ML; 5MEQ/L;160MG/100ML; 170MG/100ML; 7MMOLE/L;24.5MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L;120MG/100ML; 46MG/100ML; 200MG/100MLHEPATASOL INJ 0.77GM/100ML; 0.6GM/100ML; 3 B/D MO0.02GM/100ML; 0.9GM/100ML; 0.24GM/100ML;0.9GM/100ML; 1.1GM/100ML; 0.61GM/100ML;0.1GM/100ML; 0.1GM/100ML; 0.115GM/100ML;0.8GM/100ML; 0.5GM/100ML; 0.45GM/100ML;0.065GM/100ML; 0.84GM/100MLintralipid inj 2.25%; 20% 1 B/D MO GCIONOSOL-B/DEXTROSE 5% INJ 49MEQ/L; 5%; 425MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/LISOLYTE-P/DEXTROSE 5% INJ 23MEQ/L; 23MEQ/L; 45%; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/Lkcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45% 1 MO GCKCL 0.15%/D5W/LR INJ 3MEQ/L; 149MEQ/L; 5%; 428MEQ/L; 24MEQ/L; 130MEQ/Lkcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2% 1 MO GCkcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9% 1 MO GCkcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45% 1 MO GCKCL 0.3%/D5W/NACL 0.9% INJ 5%; 40MEQ/L; 0.9% 4lactated ringers irrigation soln 3meq/l; 109meq/l; 2 MO GC28meq/l; 4meq/l; 130meq/llactated ringers viaflex inj 3meq/l; 109meq/l; 28meq/l; 2 MO GC4meq/l; 130meq/llevocarnitine soln 1gm/10ml 2 B/D MO GClevocarnitine tabs 330mg 2 B/D MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 102

Drug NameDrugTier Requirements/LimitsNEPHRAMINE INJ 44MEQ/L; 20MG/100ML; 3 B/D MO250MG/100ML; 560MG/100ML; 880MG/100ML;640MG/100ML; 880MG/100ML; 880MG/100ML;6MEQ/L; 400MG/100ML; 200MG/100ML;640MG/100MLnormosol-m in d5w inj 16meq/l; 40meq/l; 5%; 3meq/l; 1 MO GC13meq/l; 40meq/lnormosol-r in d5w inj 27meq/l; 98meq/l; 5%; 23meq/l; 1 MO GC3meq/l; 5meq/l; 140meq/lPLASMA-LYTE-56/D5W INJ 16MEQ/L; 40MEQ/L; 5%; 43MEQ/L; 13MEQ/L; 40MEQ/Lpotassium chloride 0.15% d5w/nacl 0.33% inj 5%; 1 MO GC20meq/l; 0.33%potassium chloride 0.15% d5w/nacl 0.45% viaflex inj 1 MO GC5%; 20meq/l; 0.45%potassium chloride 0.22% d5w/nacl 0.45% inj 5%; 1 MO GC30meq/l; 0.45%potassium chloride 0.224%/dextrose 5% viaflex inj 5%; 1 MO GC30meq/lpotassium chloride 0.3%/d5w inj 5%; 40meq/l 1 MO GCPREMASOL INJ 52MEQ/L; 1760MG/100ML; 3 B/D MO880MG/100ML; 34MEQ/L; 1760MG/100ML;372MG/100ML; 406MG/100ML; 526MG/100ML;492MG/100ML; 492MG/100ML; 526MG/100ML;356MG/100ML; 356MG/100ML; 390MG/100ML;34MG/100ML; 152MG/100MLPROCALAMINE INJ 47MEQ/L; 210MG/100ML; 3 B/D MO290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML;420MG/100ML; 85MG/100ML; 210MG/100ML;270MG/100ML; 220MG/100ML; 5MEQ/L;160MG/100ML; 170MG/100ML; 7MMOLE/L; 24MEQ/L;340MG/100ML; 180MG/100ML; 35MEQ/L;120MG/100ML; 46MG/100ML; 200MG/100MLPROSOL INJ 2.76GM/100ML; 1.96GM/100ML;600MG/100ML; 1.02GM/100ML; 2.06GM/100ML;1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML;1.35GM/100ML; 760MG/100ML; 1GM/100ML;1.34GM/100ML; 1.02GM/100ML; 980MG/100ML;320MG/100ML; 50MG/100ML; 1.44GM/100ML3 B/D MOPA = 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. LA = Limited Availability: This prescription may be available only at certain pharmacies. For moreinformation consult your Provider/Pharmacy Directory or call Member 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 availablethrough mail-order service, please refer to our Evidence of Coverage for more information. ED = Excluded Drug: Thisprescription drug is not normally covered in a Medicare Prescription Drug Plan. However, Simply Healthcare Plans,Inc. does provide supplemental coverage for these medications. The amount you pay when you fill a prescription forthis drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify forcatastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get anyextra help to pay for this drug. Page 103

Drug NameDrugTier Requirements/Limitssterile water irrigation soln 0 1 MO GCTRAVASOL INJ 52MEQ/L; 1760MG/100ML; 4 B/D880MG/100ML; 34MEQ/L; 1760MG/100ML;372MG/100ML; 406MG/100ML; 526MG/100ML;492MG/100ML; 492MG/100ML; 526MG/100ML;356MG/100ML; 356MG/100ML; 390MG/100ML;34MG/100ML; 152MG/100MLTherapeutic Nutrients/Minerals/ElectrolytesElectrolyte/Mineral Replacementpotassium chloride er tbcr 8meq 1potassium chloride er tbcr 8meq 1potassium chloride sr tbcr 8meq 1potassium chloride sr tbcr 8meq 1potassium citrate tbcr 1080mg 2potassium citrate tbcr 540mg 2Vitaminsergocalciferol caps 50000unit 1 QL (4 EA per 30 days) MO GCED*folic acid tabs 1mg 1 MO GC ED*PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 104

IndexAabacavir ...........................................50abelcet..............................................33abilify ..............................................46abilify discmelt................................46abstral ................................................6acarbose...........................................56acebutolol hcl ..................................68acetaminophen/caffeine/dihydrocodeine bitartrate....................................1acetaminophen/codeine .....................1acetaminophen/codeine #3 ................1acetasol hc .....................................118acetazolamide..................................77acetazolamide er..............................77acetic acid........................................11acetylcysteine ................................122actemra ..........................................111acthar hp ........................................108acthib .............................................112actimmune .....................................111actonel ...................................113, 114actoplus met.....................................56actoplus met xr ................................56actos.................................................56acuvail ...........................................116acyclovir..........................................53acyclovir sodium .............................53aczone..............................................37adacel.............................................112adagen..............................................88adapalene.........................................86adcirca ...........................................122adderall xr........................................82adriamycin.......................................38advair diskus..................................123advair hfa.......................................123advicor.............................................72afeditab cr........................................69afinitor .....................................40, 110aggrenox..........................................64a-hydrocort ......................................94akne-mycin......................................17albenza.............................................41albuterol sulfate.............................121albuterol sulfate er.........................121alclometasone dipropionate.............94alcohol preps ...................................11aldactazide.......................................73aldurazyme...................................... 88alendronate sodium....................... 114alfuzosin hcl er................................ 93alimta .............................................. 38alinia ............................................... 41allopurinol....................................... 35alocril ............................................ 116alomide ......................................... 116alora .............................................. 100aloxi ................................................ 33alphagan p..................................... 117alprazolam................................. 53, 54alprazolam er .................................. 53alprazolam intensol......................... 53alprazolam odt .......................... 53, 54alprazolam xr .................................. 54alrex .............................................. 116altabax............................................. 11alvesco .......................................... 118amantadine hcl ................................ 42ambisome........................................ 33amcinonide...................................... 94amethia.......................................... 102amethyst........................................ 102amifostine ....................................... 38amikacin sulfate .............................. 10amiloride hcl ................................... 78amiloride/hydrochlorothiazide........ 73aminophylline ............................... 121aminosyn ii.................................... 126aminosyn m................................... 127aminosyn-hbc................................ 127aminosyn-pf .................................. 127aminosyn-pf 7%............................ 127amiodarone hcl................................ 67amitiza............................................. 91amitriptyline hcl........................ 29, 30amlodipine besylate .................. 69, 73amlodipine besylate/benazepril hcl. 73amlodipine besylate/benazeprilhydrochloride.............................. 73ammonium lactate........................... 86amnesteem ...................................... 86amoxapine....................................... 30amoxicillin ................................ 15, 16amoxicillin/clavulanate potassium.. 15amoxicillin/clavulanate potassium er.................................................... 15amoxicillin/potassium clavulanate.. 16amphetamine/dextroamphetamine. 82,83amphotec .........................................33amphotericin b.................................33ampicillin.........................................16ampicillin sodium............................16ampicillin-sulbactam .......................16ampyra.............................................85amturnide.........................................73anagrelide hydrochloride.................63anastrozole.......................................39ancobon ...........................................33androderm......................................108androgel.........................................100androgel pump...............................100androxy..........................................100antara ...............................................79apidra...............................................59apidra solostar .................................59aplenzin ...........................................26apokyn .............................................42apraclonidine .................................117apri.................................................102apriso .............................................113aptivus .............................................51aralast np .......................................122aranelle ..........................................102aranesp albumin free .......................63arcalyst ..........................................111arcapta neohaler.............................121arranon.............................................38arthrotec 50........................................1arthrotec 75........................................1arzerra..............................................40asacol.............................................113asacol hd........................................113ascomp/codeine .................................1asmanex 120 metered doses ..........118asmanex 30 metered doses ............118astepro ...........................................119astramorph.........................................6atelvia ............................................114atenolol......................................68, 73atenolol/chlorthalidone....................73atorvastatin calcium.........................79atovaquone/proguanil hcl ................41atripla...............................................53atrovent hfa....................................120aubagio ............................................85augmented betamethasonedipropionate.................................94Page 105

avandamet........................................56avandaryl .........................................56avandia ......................................56, 57avastin..............................................38avelox ..............................................18aviane ............................................102avodart.............................................93avonex .............................................85axert.................................................36azasan ............................................110azasite..............................................17azathioprine ...................................110azathioprine sodium ......................110azelastine hcl .........................116, 119azelex...............................................86azilect ........................................44, 45azithromycin....................................17azopt ..............................................117azor............................................73, 74aztreonam ........................................15Bbacitracin .................................11, 115bacitracin/polymyxin b..................115baclofen ...........................................49bactroban .........................................11bactroban nasal................................11balsalazide disodium .....................113balziva ...........................................102banzel ..............................................23baraclude .........................................52bd insulin syringe safetyglide/1ml/29gx 1/2.............................................59bd insulin syringe ultrafine/0.3ml/31gx 5/16...........................................59bd insulin syringe ultrafine/0.5ml/30gx 1/2.............................................59bd insulin syringe ultrafine/1ml/31g x5/16..............................................59bd pen needle/ultrafine/29g x 12.7mm.....................................................59benazepril hcl ............................66, 74benazepril hcl/hydrochlorothiazide.74benicar .......................................65, 74benicar hct .......................................74benztropine mesylate.......................42bepreve ..........................................116besivance .........................................18betamethasone dipropionate......86, 95betamethasone valerate ...................95betaseron..........................................85betaxolol hcl............................ 68, 117bethanechol chloride....................... 93betimol .......................................... 117betoptic-s....................................... 117bicalutamide.................................. 110bicillin c-r........................................ 16bicillin l-a........................................ 16biltricide.......................................... 41bisoprolol fumarate................... 68, 74bisoprololfumarate/hydrochlorothiazide..... 74blephamide.................................... 115blephamide s.o.p. .......................... 115boostrix ......................................... 112bosulif ............................................. 40botox ............................................... 36briellyn.......................................... 102brimonidine tartrate ...................... 117bromday ........................................ 116bromfenac ..................................... 116bromocriptine mesylate .................. 42brovana ......................................... 121budeprion sr .................................... 26budesonide .............................. 91, 118bumetanide...................................... 77buphenyl ......................................... 88buprenorphine hcl ........................... 10buproban ......................................... 26bupropion hcl .................................. 26bupropion hcl sr .............................. 26buspirone hcl................................... 54butalbital/acetaminophen/caffeine/codeine................................................ 1butorphanol tartrate........................... 9butrans............................................... 1bydureon ......................................... 57byetta............................................... 57bystolic............................................ 68Ccabergoline.................................... 108calcipotriene.................................... 86calcitonin-salmon.......................... 114calcitriol .................................. 86, 114calcium acetate................................ 94camila............................................ 104campath........................................... 38campral ........................................... 10canasa............................................ 113cancidas........................................... 33capex ............................................... 95caprelsa............................................40captopril.....................................66, 74captopril/hydrochlorothiazide .........74carac ................................................86carafate ............................................91carbaglu ...........................................88carbamazepine...........................23, 55carbamazepine er.......................23, 55carbidopa/levodopa ...................43, 44carbidopa/levodopa er .....................43carbidopa/levodopa/entacapone ......44carbinoxamine maleate..................119carboplatin.......................................38carimune nanofiltered....................111carisoprodol...............................1, 124carisoprodol/aspirin...........................1carisoprodol/aspirin/codeine .............1carteolol hcl...................................117cartia xt............................................70carvedilol.........................................68cayston.............................................15ceenu................................................37cefaclor............................................13cefadroxil.........................................13cefazolin sodium .............................13cefdinir ............................................14cefepime ..........................................14cefotaxime sodium ..........................14cefotetan ..........................................14cefoxitin sodium..............................14cefpodoxime proxetil.......................14cefprozil...........................................14ceftazidime ......................................14ceftriaxone sodium ..........................14cefuroxime axetil.............................14cefuroxime sodium..........................14celebrex .............................................3celestone..........................................95cellcept ..........................................110celontin............................................21cenestin..........................................100cephalexin........................................14cerezyme..........................................88cervarix..........................................112cetirizine hcl ..................................119cevimeline hcl .................................86chantix .............................................11chantix starting month pak ..............11chenodal ..........................................90chlordiazepoxide/amitriptyline........27chlorhexidine gluconate oral rinse ..86Page 106

chloroquine phosphate.....................41chlorothiazide..................................78chlorpromazine hcl..........................31chlorpropamide................................57chlorthalidone..................................78chlorzoxazone................................124cholestyramine light ........................80cialis ................................................94ciclopirox...................................33, 34ciclopirox nail lacquer.....................33ciclopirox olamine...........................33cilostazol..........................................64ciloxan .............................................18cimetidine........................................90cimetidine hcl ..................................90cimzia ............................................110cinryze .............................................63cipro.........................................18, 118cipro hc..........................................118ciprodex.........................................118ciprofloxacin....................................18ciprofloxacin er ...............................18ciprofloxacin hcl..............................18citalopram hydrobromide ................28claravis ......................................86, 87clarithromycin .................................17clarithromycin er .............................17cleocin .............................................12cleocin pediatric granules................12climara pro.....................................102clindamycin hcl ...............................12clindamycin phosphate....................12clindamycin phosphate add-vantage12clindamycin/benzoyl peroxide ........87clinimix 2.75%/dextrose 5% .........127clinimix 4.25%/dextrose 10% .......128clinimix 4.25%/dextrose 20% .......128clinimix 4.25%/dextrose 25% .......128clinimix 4.25%/dextrose 5% .........128clinimix 5%/dextrose 15% ............129clinimix 5%/dextrose 20% ............129clinimix 5%/dextrose 25% ............129clinimix e 2.75%/dextrose 10% ....129clinimix e 2.75%/dextrose 5% ......130clinimix e 4.25%/dextrose 25% ....130clinimix e 4.25%/dextrose 5% ......130clinimix e 5%/dextrose 15% .........130clinimix e 5%/dextrose 20% .........131clinimix e 5%/dextrose 25% .........131clinisol sf 15%...............................131clobetasol propionate.......................95clobetasol propionate e ................... 95clomipramine hcl ............................ 30clonazepam ..................................... 54clonazepam odt ............................... 54clonidine hcl.................................... 64clopidogrel ...................................... 64clorazepate dipotassium............ 54, 55clorpres ........................................... 74clotrimazole .............................. 34, 87clotrimazole/betamethasonedipropionate ................................ 87clozapine ................................... 48, 49clozapine odt............................. 48, 49codeine sulfate .................................. 9co-gesic ............................................. 1colcrys............................................. 35colestipol hcl................................... 80colistimethate sodium ..................... 13colocort ......................................... 113coly-mycin s.................................. 118colyte-flavor packs.......................... 91combigan....................................... 117combipatch.................................... 102combivent ............................. 120, 123combivent respimat....................... 120complera ......................................... 50compro ............................................ 31comtan............................................. 42comvax.......................................... 112condylox ......................................... 87constulose ....................................... 91copaxone ......................................... 85cordran ............................................ 95cordran tape .................................... 95coreg cr ........................................... 68cortisone acetate.............................. 95cortisporin ............................... 87, 118cortisporin-tc................................. 118coumadin......................................... 61creon ............................................... 88crestor ............................................. 79crinone .......................................... 104crixivan ........................................... 51cromolyn sodium .................. 116, 122cryselle-28..................................... 102cubicin............................................. 12curity gauze pads 2 ......................... 59cyclafem 1/35................................ 102cyclafem 7/7/7 .............................. 102cyclobenzaprine hcl ...................... 124cyclobenzaprine hcl er .................. 124cyclophosphamide...........................37cycloset............................................57cyclosporine ..................................110cyclosporine modified...................110cymbalta ..........................................28cyproheptadine hcl ........................119cytarabine aqueous ..........................39Ddacogen............................................39daliresp ..........................................123danazol ..........................................100dantrolene sodium ...........................49dapsone............................................37daptacel..........................................112daraprim ..........................................41daytrana ...........................................84decavac..........................................112demeclocycline hcl....................19, 20denavir.............................................53depen titratabs .................................94depo-estradiol................................101depo-provera..................................104depo-subq provera 104..................104derma-smoothe/fs body oil..............95dermotic.........................................118desipramine hcl ...............................30desloratadine..................................120desmopressin acetate.......................99desonate...........................................95desonide...........................................95desowen...........................................95desoximetasone .................95, 96, 107detrol................................................92detrol la............................................92dexamethasone ........................96, 116dexamethasone intensol...................96dexamethasone sodium phosphate .96,116dexilant............................................92dexmethylphenidate hcl...................84dexrazoxane.....................................39dextroamphetamine sulfate .......83, 84dextroamphetamine sulfate er .........83dextrose 10% flex container..........131dextrose 10%/nacl 0.2%................131dextrose 2.5%/sodium chloride 0.45%...................................................131dextrose 5%...........................131, 132dextrose 5%/lactated ringers .........131dextrose 5%/nacl 0.2%..................131Page 107

dextrose 5%/nacl 0.33%................131dextrose 5%/nacl 0.45%................132dextrose 5%/nacl 0.9%..................132dextrose 5%/potassium chloride0.15%.........................................132diazepam..........................................55dibenzyline ......................................64diclofenac potassium.........................3diclofenac sodium .....................4, 116diclofenac sodium dr .........................4diclofenac sodium er .........................4diclofenac sodium/misoprostol .........4dicloxacillin sodium ..................16, 17dicyclomine hcl ...............................89didanosine........................................50dificid ..............................................17diflorasone diacetate........................96diflunisal............................................4digoxin.............................................72dihydroergotamine mesylate ...........36dilantin.............................................24dilantin infatabs...............................24dilatrate sr........................................80dilaudid-5 ..........................................9dilt-cd ..............................................70diltiazem cd .....................................70diltiazem hcl ....................................70diltiazem hcl er................................70dilt-xr...............................................70diovan..............................................65dipentum........................................113diphenhydramine hcl.......................31diphenoxylate/atropine....................90dipyridamole....................................64disopyramide phosphate..................67disulfiram ........................................10divalproex sodium.....................21, 22divalproex sodium dr.................21, 22divalproex sodium er.......................22divigel............................................101docetaxel..........................................39donepezil hcl ...................................25doribax.............................................15dorzolamide hcl.............................117dorzolamide hcl/timolol maleate...117dovonex ...........................................87doxazosin mesylate ...................64, 65doxepin hcl ......................................30doxil.................................................39doxycycline .....................................20doxycycline hyclate.........................20doxycycline monohydrate............... 20dronabinol ....................................... 33droxia .............................................. 38Drug Name........................................ 1dulera ............................................ 121durezol .......................................... 116dynacirc cr ...................................... 70dyrenium ......................................... 78Ee.e.s. 400 ......................................... 17e.e.s. granules.................................. 18econazole nitrate ............................. 34edarbi .............................................. 65edecrin............................................. 78edurant ............................................ 49effient.............................................. 64elestat ............................................ 116elestrin........................................... 101elidel ............................................... 87eligard ........................................... 108eliphos............................................. 94elixophyllin ................................... 121elmiron............................................ 94eloxatin ........................................... 39emadine......................................... 116emcyt............................................... 38emend.............................................. 33emoquette...................................... 102emsam ............................................. 27emtriva ............................................ 50enablex............................................ 92enalapril maleate....................... 66, 75enalapril maleate/hydrochlorothiazide.................................................... 75enbrel ............................................ 110endocet.............................................. 1endodan............................................. 1engerix-b ....................................... 112enjuvia........................................... 101enoxaparin sodium.................... 61, 64enpresse-28 ................................... 102entacapone ...................................... 42enulose ............................................ 91epinastine hcl ................................ 116epinephrine hcl.............................. 121epipen 2-pak.................................. 121epipen-jr 2-pak.............................. 121epitol ............................................... 24epivir ......................................... 50, 52epivir hbv ........................................ 52eplerenone .......................................78eprosartan mesylate.........................65epzicom ...........................................50equetro.............................................24erbitux..............................................39ergocalciferol.................................135ergoloid mesylates...........................25erivedge ...........................................39errin ...............................................104ertaczo .............................................34ery....................................................18eryped 200.......................................18eryped 400.......................................18ery-tab..............................................18erythrocin stearate ...........................18erythromycin .............................18, 87erythromycin ethylsuccinate ...........18erythromycin/benzoyl peroxide.......87escitalopram oxalate........................28estrace............................................101estradiol .................................101, 102estradiol valerate ...........................101estradiol/norethindrone acetate .....102estring............................................101estropipate .....................................101ethambutol hcl.................................37ethosuximide ...................................21etidronate disodium.......................114etodolac .............................................4etodolac er .........................................4etoposide..........................................39eurax................................................41evamist ..........................................101evista..............................................105evoxac..............................................86exalgo ................................................6exelderm..........................................34exelon ..............................................25exemestane ......................................39exforge.......................................70, 71exforge hct.......................................70exjade ............................................125extavia .............................................85Ffabrazyme........................................88factive..............................................18famciclovir ......................................53famotidine........................................90fanapt...............................................46fareston............................................38Page 108

faslodex ...........................................39fazaclo .............................................49felbamate .........................................22felodipine er.....................................71femhrt low dose.............................103femring ..........................................101femtrace.........................................101fenofibrate .......................................79fenofibrate micronized ....................79fenoglide..........................................79fenoprofen calcium............................4fentanyl..............................................6fentanyl citrate oral transmucosal .....6fentora................................................7finacea .............................................87finasteride........................................93firmagon ........................................108flarex..............................................116flavoxate hcl ....................................92flecainide acetate.............................67flector ................................................4flovent diskus ................................119flovent hfa .....................................119fluconazole ......................................34fluconazole in dextrose....................34flucytosine .......................................34fludrocortisone acetate ....................96flunisolide......................................119fluocinolone acetonide ....................96fluocinonide.....................................96fluocinonide-e..................................96fluoroplex ........................................87fluorouracil......................................87fluoxetine hcl...................................28fluphenazine decanoate ...................45fluphenazine hcl ..............................45flurbiprofen................................4, 116flurbiprofen sodium.......................116flutamide........................................110fluticasone propionate .......96, 97, 119fluvastatin........................................79fluvoxamine maleate .......................28fml .................................................116fml forte.........................................116focalin xr .........................................84folic acid........................................135fondaparinux sodium.................61, 62foradil aerolizer .............................121forfivo xl..........................................26forteo .............................................114fortical ...........................................114fosamax plus d .............................. 114foscarnet sodium............................. 49fosinopril sodium...................... 66, 75fosinopril sodium/hydrochlorothiazide.................................................... 75fosrenol ........................................... 94fragmin............................................ 62freamine iii 3% ............................. 132frova................................................ 36furosemide ...................................... 78fuzeon ............................................. 51Ggabapentin....................................... 22gabitril............................................. 22galantamine hydrobromide ............. 25gamastan s/d.................................. 111gammagard liquid ......................... 111ganciclovir ...................................... 49gardasil.......................................... 112gavilyte-c ........................................ 90gavilyte-g ........................................ 90gavilyte-n/flavor pack..................... 90gelnique........................................... 93gemcitabine hcl............................... 38gemfibrozil...................................... 79generlac........................................... 91gengraf .......................................... 110genotropin ....................................... 99genotropin miniquick...................... 99gentak.............................................. 10gentamicin sulfate........................... 11gentamicin sulfate/0.9% sodiumchloride ....................................... 11geodon............................................. 46gianvi ............................................ 103gilenya............................................. 85gleevec ............................................ 40glimepiride...................................... 57glipizide .................................... 57, 58glipizide er ...................................... 57glipizide/metformin hcl .................. 58glucagen hypokit............................. 59glucagon emergency kit.................. 59glyburide ............................. 57, 58, 59glyburide micronized ...................... 57glyburide/metformin hcl ........... 58, 59glycopyrrolate ................................. 89glyset............................................... 57golytely ........................................... 91granisetron hcl ................................ 33griseofulvin microsize.....................34griseofulvin ultramicrosize..............34gris-peg............................................34guanfacine hcl .................................64Hhalflytely bowel prep/flavor packs..91halobetasol propionate.....................97halog................................................97haloperidol.......................................45haloperidol decanoate......................45haloperidol lactate ...........................45havrix.............................................112hectorol..........................................114helidac .............................................90heparin sodium ................................62heparin sodium/nacl 0.45%.............62hepatasol........................................132hepsera.............................................52herceptin..........................................39hexalen ............................................37humalog...........................................60humalog kwikpen ............................60humalog mix 50/50..........................60humalog mix 50/50 kwikpen...........60humalog mix 75/25..........................60humalog mix 75/25 kwikpen...........60humatrope........................................99humira............................................110humulin 70/30 .................................60humulin 70/30 pen...........................60humulin n.........................................60humulin n u-100 pen .......................60humulin r .........................................60humulin r u-500 (concentrated).......60hydralazine hcl ................................82hydrochlorothiazide.........................78hydrocodone bitartrate/acetaminophen.......................................................2hydrocodone bitartrate/homatropinemethylbromide ..........................123hydrocodone/acetaminophen.............2hydrocodone/ibuprofen .....................3hydrocortisone.................97, 107, 113hydrocortisone butyrate.................107hydrocortisone valerate ...................97hydromorphone hcl ...........................9hydroxychloroquine sulfate.............41hydroxyurea.....................................38hydroxyzine hcl...............................31hydroxyzine pamoate ......................31Page 109

Iibandronate sodium .......................114ibuprofen ...........................................4imipenem/cilastatin .........................15imipramine hcl.................................30imipramine pamoate........................30imiquimod .......................................87imitrex .............................................36imovax rabies (h.d.c.v.).................112incivek .............................................52increlex............................................99indapamide ......................................78indocin...............................................4indomethacin .....................................5indomethacin er.................................5infanrix ..........................................112inlyta................................................39innopran xl.......................................68intelence ..........................................49intralipid ........................................132intron-a ............................................52intron-a w/diluent ............................52introvale.........................................103intuniv..............................................84invanz ..............................................15invega ........................................46, 47invega sustenna .........................46, 47invirase ............................................51ionosol-b/dextrose 5%...................132ipol inactivated ipv........................112ipratropium bromide..............120, 123ipratropium bromide/albuterol sulfate...................................................123irbesartan ...................................65, 75irbesartan/hydrochlorothiazide........75irinotecan.........................................39isentress ...........................................51isolyte-p/dextrose 5%....................132isoniazid ..........................................37isordil titradose................................80isosorbide dinitrate ....................80, 81isosorbide dinitrate er......................80isosorbide mononitrate ....................81isosorbide mononitrate er................81isotonic gentamicin .........................11isradipine .........................................71istalol .............................................117itraconazole .....................................34ixempra kit.......................................39ixiaro..............................................112Jjakafi ............................................... 39jalyn ................................................ 93jantoven........................................... 62janumet ........................................... 59janumet xr ....................................... 59januvia............................................. 57jevtana............................................. 39jinteli............................................. 103jolivette ......................................... 104junel 1.5/30 ................................... 103junel 1/20 ...................................... 103junel fe 1.5/30 ............................... 103junel fe 1/20 .................................. 103Kkaletra ............................................. 51kalydeco........................................ 123kanamycin sulfate ........................... 11kariva ............................................ 103kcl 0.075%/d5w/nacl 0.45% ......... 132kcl 0.15%/d5w/lr........................... 132kcl 0.15%/d5w/nacl 0.2% ............. 132kcl 0.15%/d5w/nacl 0.9% ............. 132kcl 0.3%/d5w/nacl 0.45% ............. 133kcl 0.3%/d5w/nacl 0.9% ............... 133kelnor 1/35 .................................... 103kenalog............................................ 97ketoconazole ................................... 34ketoprofen ......................................... 5ketoprofen er..................................... 5ketorolac tromethamine ............ 5, 116kineret ........................................... 110kionex ........................................... 125klor-con 10.................................... 125klor-con 8...................................... 125klor-con m15................................. 125klor-con m20................................. 125kombiglyze xr ................................. 59kristalose ......................................... 91kuvan............................................... 88Llabetalol hcl..................................... 68laclotion .......................................... 87lactated ringers irrigation.............. 133lactated ringers viaflex.................. 133lactulose .......................................... 91lamictal odt ............................... 22, 23lamictal starter/not takingcarbamazepine.............................23lamictal starter/takingcarbamazepine/not taking valproate.....................................................23lamictal starter/taking valproate......23lamictal xr........................................23lamivudine.......................................50lamivudine/zidovudine....................50lamotrigine ......................................23lanoxin.............................................72lansoprazole.....................................92lantus ...............................................60lantus solostar..................................60lastacaft..........................................116latanoprost .....................................118latuda ...............................................47leena ..............................................103leflunomide....................................111lescol xl ...........................................79lessina............................................103letairis............................................122letrozole...........................................39leucovorin calcium ..........................38leukeran ...........................................37leukine .............................................63leuprolide acetate...........................108levalbuterol....................................122levatol..............................................68levemir.............................................60levemir flexpen................................60levetiracetam ...................................20levetiracetam er ...............................20levobunolol hcl..............................117levocarnitine..................................133levocetirizine dihydrochloride.......120levofloxacin.....................................19levofloxacin in d5w.........................19levora 0.15/30-28 ..........................103levothroid ......................................105levothyroxine sodium............105, 106levoxyl...........................................106lexiva ...............................................51lialda..............................................113lidocaine ..........................................10lidocaine hcl ....................................10lidocaine hcl jelly ............................10lidocaine viscous .............................10lidocaine/prilocaine .........................10lidoderm ..........................................10lincocin............................................12lindane .............................................41Page 110

linzess..............................................91liothyronine sodium.......................106lipodox.............................................38lipodox 50........................................38lipofen..............................................79lisinopril ....................................66, 75lisinopril/hydrochlorothiazide .........75lithium carbonate.......................55, 56lithium carbonate er...................55, 56lithium citrate ..................................56livalo..........................................79, 80locoid lipocream..............................97lodosyn ............................................43lofibra ..............................................79loperamide hcl.................................90lorazepam ........................................55lorazepam intensol...........................55losartan potassium.....................65, 75losartanpotassium/hydrochlorothiazide ...75lotemax..................................116, 117lotronex............................................91lovastatin .........................................80lovaza ..............................................80lovenox............................................62low-ogestrel...................................103loxapine succinate ...........................45lufyllin ...........................................121lumigan..........................................118lunesta............................................124lupron depot...................................109lupron depot-ped ...........................109lutera..............................................103lyrica................................................21lysodren .........................................108Mmacrodantin.....................................12malathion.........................................41maprotiline hcl.................................26marlissa..........................................103marplan............................................27matulane ..........................................37matzim la.........................................71maxair autohaler............................122maxalt..............................................36maxalt-mlt .......................................36maxidex .........................................117meclizine hcl ...................................32meclofenamate sodium......................5medroxyprogesterone acetate 104, 105mefenamic acid................................. 5mefloquine hcl ................................ 41megestrol acetate .......................... 105meloxicam......................................... 5menactra........................................ 112menest ........................................... 101menomune-a/c/y/w-135 ................ 112menostar........................................ 101mentax............................................. 34menveo.......................................... 112meperidine hcl .................................. 9meperitab .......................................... 9meprobamate................................... 55mepron ............................................ 41mercaptopurine ............................. 110meropenem ..................................... 15mesalamine ................................... 113mesna .............................................. 39mesnex ............................................ 39mestinon.......................................... 37mestinon timespan .......................... 37metadate cd ..................................... 84metadate er...................................... 84metaproterenol sulfate .................. 122metformin hcl............................ 57, 58metformin hcl er ............................. 57methadone hcl................................... 7methamphetamine hcl..................... 84methazolamide................................ 77methenamine hippurate................... 12methimazole.................................. 110methitest........................................ 100methocarbamol ............................. 124methotrexate ......................... 110, 111methotrexate sodium..................... 110methscopolamine bromide.............. 90methyclothiazide............................. 78methyldopa ............................... 64, 75methyldopa/hydrochlorothiazide .... 75methylphenidate hcl.................. 84, 85methylphenidate hcl cd ................... 84methylphenidate hcl er.................... 84methylphenidate hydrochloride ...... 85methylprednisolone................. 97, 108methylprednisolone acetate ............ 97methylprednisolone dose pack........ 97methylprednisolone sodiumsuccinate............................................ 97, 108metipranolol.................................. 117metoclopramide hcl ........................ 32metolazone...................................... 78metoprolol succinate er ...................69metoprolol tartrate...........................69metoprolol/hydrochlorothiazide 75, 76metrogel...........................................12metronidazole..................................12metronidazole in nacl 0.79%...........12metronidazole vaginal .....................12mexiletine hcl ..................................67micardis .....................................65, 76micardis hct .....................................76miconazole 3 ...................................34microgestin 1.5/30.........................103microgestin 1/20............................103microgestin fe................................103microgestin fe 1.5/30.....................103midodrine hcl...................................64migergot ..........................................36migranal...........................................36millipred ..................................97, 117minitran ...........................................81minocycline hcl .........................20, 86minoxidil .........................................82mirtazapine......................................26mirtazapine odt................................26misoprostol......................................92mitomycin........................................39mitoxantrone hcl..............................38m-m-r ii w/diluent 10 dose............112modafinil .......................................125moexipril hcl ...................................66moexipril/hydrochlorothiazide........76mometasone furoate ........................98mononessa .....................................103montelukast sodium.......................120monurol ...........................................12morphine sulfate................................7morphine sulfate er............................7moviprep..........................................91moxeza ............................................19ms contin ...........................................7multaq..............................................67mupirocin ........................................13mustargen ........................................39mycamine ..................................34, 35mycobutin........................................37mycophenolate mofetil..................111myfortic .........................................111myozyme .........................................88Nnabumetone .......................................5Page 111

nadolol.......................................69, 76nadolol/bendroflumethiazide...........76nafcillin sodium...............................17naftin................................................35naglazyme........................................88nalbuphine hcl ...................................9nalfon...............................................79naloxone hcl ....................................10naltrexone hcl ..................................10namenda ..........................................26namenda titration pak......................26naproxen......................................5, 10naproxen dr........................................5naproxen sodium ...............................5naratriptan hcl..................................36nasonex..........................................119natacyn ............................................35nateglinide .......................................58nebupent ..........................................41necon 0.5/35-28.............................103necon 1/35 .....................................103necon 7/7/7 ....................................103nefazodone hcl.................................26neomycin sulfate .............................11neomycin/bacitracin/polymyxin....115neomycin/polymyxin/bacitracin/hydrocortisone ....................................115neomycin/polymyxin/dexamethasone...................................................115neomycin/polymyxin/gramicidin ..115neomycin/polymyxin/hc................118neomycin/polymyxin/hydrocortisone...........................................115, 118nephramine....................................133neulasta............................................63neumega ..........................................63neupogen .........................................63nevanac..........................................117nevirapine........................................49nexavar ............................................40nexium.............................................92nexium i.v........................................92next choice.....................................105niacor...............................................80niaspan.............................................80nicardipine hcl.................................71nicotrol ns........................................10nifediac cc .......................................71nifedical xl.......................................71nifedipine.........................................71nifedipine er.....................................71nilandron ....................................... 110nimodipine ...................................... 71nisoldipine....................................... 71nisoldipine er .................................. 71nitro-bid .......................................... 81nitrofurantoin .................................. 13nitrofurantoin macrocrystalline ...... 13nitrofurantoin monohydrate ............ 13nitroglycerin.............................. 81, 82nitroglycerin lingual........................ 82nitroglycerin transdermal................ 81nitrolingual pumpspray................... 81nitromist.......................................... 81nitrostat ........................................... 81nizatidine......................................... 91nora-be .......................................... 105norditropin flexpro.......................... 99norditropin nordiflex pen................ 99norethindrone acetate.................... 105normosol-m in d5w....................... 133normosol-r in d5w......................... 133norpace cr........................................ 67nortrel 0.5/35 (28)......................... 103nortrel 1/35.................................... 103nortrel 7/7/7 .................................. 103nortriptyline hcl .............................. 30norvir............................................... 51novarel .......................................... 108novolin 70/30.................................. 60novolin n ......................................... 60novolin r.......................................... 60novolog ..................................... 60, 61novolog flexpen .............................. 60novolog mix 70/30.......................... 61novolog mix 70/30 prefilled flexpen61noxafil............................................. 35nucynta.......................................... 8, 9nucynta er.......................................... 8nuedexta.......................................... 85nutropin aq pen ............................... 99nuvigil ........................................... 125nystatin...................................... 35, 87nystatin/triamcinolone .................... 87nystop.............................................. 35Oocella............................................. 103octreotide acetate .......................... 109ofloxacin ......................................... 19olanzapine ................................. 29, 47olanzapine odt................................. 47olanzapine/fluoxetine ......................29omeprazole ......................................92omnitrope ......................................100ondansetron hcl ...............................33ondansetron odt ...............................33onfi ..................................................20onglyza ............................................58onsolis................................................8opana er (crush resistant)...................8orap..................................................45orapred odt...............................98, 117orencia ...........................................111orfadin .......................................88, 89orphenadrine citrate.......................124orphenadrine citrate er...................124orphenadrine/asa/caffeine..................3orsythia..........................................104osmoprep .......................................125oxandrolone...................................100oxaprozin...........................................5oxcarbazepine..................................24oxistat ..............................................35oxsoralen ultra.................................87oxybutynin chloride.........................93oxybutynin chloride er ....................93oxycodone hcl ...................................9oxycodone/acetaminophen................3oxycodone/aspirin .............................3oxycodone/ibuprofen.........................5oxycontin...........................................8oxymorphone hydrochloride .........8, 9oxymorphone hydrochloride er .........8oxytrol .............................................93Ppacerone ..........................................67paclitaxel .........................................39pamidronate disodium...................114pancreaze.........................................89pandel ..............................................98panretin............................................40pantoprazole sodium .......................92paromomycin sulfate.......................11paroxetine hcl ............................28, 29paroxetine hcl er..............................28pataday ..........................................116patanase .........................................120patanol ...........................................116paxil.................................................29pedi-dri ............................................35pedvax hib .....................................112Page 112

peganone..........................................24pegasys ............................................52pegasys proclick ..............................52peg-intron ........................................52peg-intron redipen ...........................52penicillin g potassium......................17penicillin g potassium in iso-osmoticdextrose .......................................17penicillin g sodium..........................17penicillin v potassium......................17pennsaid.............................................5pentasa...........................................113pentazocine/acetaminophen ..............3pentazocine/naloxone hcl ..................3pentoxifylline er ..............................72perforomist ....................................122perindopril erbumine.......................66periogard..........................................86permethrin .......................................41perphenazine..............................27, 32perphenazine/amitriptyline..............27pertzye .............................................89pexeva..............................................29phenadoz..........................................32phenelzine sulfate............................27phenobarbital...................................21phenytek ..........................................24phenytoin.........................................24phenytoin infatabs ...........................24phenytoin sodium extended.............24phisohex ..........................................87phoslyra ...........................................94phospholine iodide ........................117pilocarpine hcl.................................86pilocarpine hydrochloride ...............86pilopine hs .....................................117pindolol............................................69pioglitazone hcl ...............................58pioglitazone hcl/metformin hcl .......58piperacillin sodium/tazobactamsodium .........................................17piroxicam...........................................6plasma-lyte-148.............................125plasma-lyte-56/d5w.......................133podofilox .........................................87polyethylene glycol 3350 ................91portia-28 ........................................104potassium chloride.125, 126, 133, 134potassium chloride 0.15% /nacl 0.45%viaflex........................................125potassium chloride 0.15% d5w/nacl0.33% ........................................ 133potassium chloride 0.15% d5w/nacl0.45% viaflex........................... 133potassium chloride 0.15% nacl 0.9%.................................................. 125potassium chloride 0.22% d5w/nacl0.45% ........................................ 133potassium chloride 0.224%/dextrose5% viaflex................................. 133potassium chloride 0.3%/d5w....... 133potassium chloride er.... 125, 126, 134potassium chloride sr .................... 134potassium citrate ........................... 135potiga .............................................. 21pradaxa............................................ 62pramipexole dihydrochloride.... 42, 43prandimet ........................................ 59prandin ............................................ 58pravastatin sodium .......................... 80prazosin hcl..................................... 65pred mild....................................... 117pred-g............................................ 115prednicarbate................................... 98prednisolone acetate...................... 117prednisolone sodium phosphate..... 98,117prednisone....................................... 98prednisone intensol ......................... 98prefest ........................................... 104pregnyl w/diluent benzyl alcohol/nacl.................................................. 100premarin........................................ 102premasol........................................ 134premphase ..................................... 104prempro......................................... 104prevalite .......................................... 80previfem........................................ 104prevpac............................................ 90prezista............................................ 51primidone........................................ 22pristiq .............................................. 29proair hfa....................................... 122probenecid....................................... 35probenecid/colchicine ..................... 35procalamine................................... 134prochlorperazine edisylate .............. 32prochlorperazine maleate................ 32procrit.............................................. 63proctocream hc.............................. 113procto-pak ..................................... 108proctozone-hc ............................... 108progesterone ..................................105proglycem........................................59prolastin-c......................................123proleukin..........................................39prolia..............................................114promacta..........................................63promethazine hcl .............................32promethazine vc ............................123promethazine vc/codeine...............123promethazine/codeine....................123promethazine/dextromethorphan...123promethegan....................................32propafenone hcl...............................67propafenone hcl er...........................67propranolol hcl ................................69propranolol hcl er ............................69propranolol/hydrochlorothiazide.....76propylthiouracil .............................110proquad..........................................112prosol.............................................134protopic............................................87protriptyline hcl...............................31proventil hfa ..................................122pulmicort flexhaler ........................119pulmozyme....................................124pylera...............................................90pyridostigmine bromide ..................37Qqualaquin .........................................41quasense ........................................104quetiapine fumarate.........................47quinapril hcl.....................................66quinapril/hydrochlorothiazide .........76quinidine gluconate er .....................67quinidine sulfate ..............................67quinidine sulfate er..........................67qvar................................................119Rrabavert..........................................112ramipril......................................66, 67ranexa ..............................................72ranitidine hcl....................................91rapaflo..............................................93rapamune .......................................111rebif .................................................86rebif titration pack ...........................86reclast ............................................114reclipsen ........................................104recombivax hb...............................112Page 113

egranex...........................................87relenza diskhaler..............................52relistor..............................................90relpax...............................................36remicade ........................................111renvela .............................................94reprexain............................................3rescriptor....................................49, 50reserpine ..........................................76restasis ...........................................115retrovir iv infusion...........................50revatio............................................122revlimid .....................................37, 38reyataz .......................................51, 52rheumatrex.....................................111rhinocort aqua................................119ribapak.............................................52ribasphere ..................................52, 53ribavirin ...........................................53ridaura............................................111rifampin ...........................................37rifater ...............................................37rilutek ..............................................85rimantadine hcl................................52risperdal consta..........................47, 48risperidone.......................................48risperidone odt.................................48rituxan..............................................40rivastigmine tartrate.........................25rizatriptan benzoate .........................36ropinirole er.....................................43ropinirole hcl ...................................43rotateq............................................113roxicet................................................3rozerem..........................................125Ssabril................................................22saizen click.easy............................100samsca ...........................................125sanctura xr .......................................93sancuso ............................................33sandostatin lar depot......................109santyl ...............................................87saphris..............................................48savella..............................................85savella titration pack........................85selegiline hcl....................................45selenium sulfide...............................87selzentry ..........................................51sensipar..........................................108serevent diskus.............................. 122seroquel xr ................................ 26, 27sertraline hcl.................................... 29sildenafil citrate ............................ 122silenor ............................................. 31silver sulfadiazine ........................... 19simcor ....................................... 76, 80simponi ......................................... 111simvastatin ...................................... 80singulair ........................................ 120sklice ............................................... 41sodium chloride ............................ 126sodium chloride 0.45% viaflex ..... 126sodium chloride 0.9% ................... 126sodium sulfacetamide ..................... 19solaraze ........................................... 88solu-cortef ....................................... 98soma.............................................. 124somatuline depot........................... 109somavert........................................ 109soriatane.......................................... 88sorine......................................... 67, 68sotalol hcl........................................ 68sotalol hcl (af) ................................. 68spectracef ........................................ 14spiriva handihaler.......................... 120spironolactone........................... 76, 78spironolactone/hydrochlorothiazide 76sporanox.......................................... 35sprintec 28..................................... 104sprycel............................................. 40sronyx ........................................... 104ssd ................................................... 13stagesic.............................................. 3stalevo 100 ...................................... 42stalevo 125 ...................................... 42stalevo 150 ...................................... 42stalevo 200 ...................................... 42stalevo 50 ........................................ 42stalevo 75 ........................................ 42stavudine ......................................... 50stavzor............................................. 22stelara.............................................. 88sterile water irrigation................... 134stivarga............................................ 40strattera ........................................... 85striant ............................................ 100stribild............................................. 50stromectol ....................................... 41suboxone......................................... 10sucralfate......................................... 92sulfacetamide sodium..............19, 115sulfacetamide sodium/prednisolonesodium phosphate......................115sulfadiazine......................................19sulfamethoxazole/trimethoprim ......19sulfamethoxazole/trimethoprim ds..19sulfamylon.......................................13sulfasalazine ..................................113sulfazine ec....................................113sulindac..............................................6sumatriptan succinate ......................36suprax ..............................................15suprep bowel prep .........................126sustiva..............................................50sutent ...............................................40sylatron............................................53symbicort.......................................124symbyax ..........................................27symlinpen 120 .................................58symlinpen 60 ...................................58synalgos-dc........................................3synarel ...........................................109synercid ...........................................13synthroid................................106, 107Ttabloid..............................................38taclonex ...........................................88tacrolimus......................................111tamiflu .............................................52tamoxifen citrate..............................38tamsulosin hcl..................................93tarceva .............................................40targretin ...........................................40tarka.................................................76tasigna..............................................40tasmar ..............................................42taxotere............................................39tazorac .............................................88taztia xt ......................................71, 72teflaro ..............................................15tegretol.............................................24tegretol-xr........................................24tekamlo......................................76, 77tekturna......................................72, 77tekturna hct......................................77temazepam.......................................55terazosin hcl.....................................65terbinafine hcl..................................35terbutaline sulfate ..........................122terconazole ......................................35Page 114

testosterone cypionate ...................100testosterone enanthate ...................100testred ............................................100tetanus toxoid adsorbed.................113tetanus/diphtheria toxoids-adsorbedadult...........................................113tetracycline hcl ................................20tev-tropin .......................................100thalitone...........................................79thalomid...........................................38theophylline cr...............................121theophylline er...............................121thermazene ......................................13thioridazine hcl..........................45, 46thiothixene.......................................46tiagabine hydrochloride...................22ticlopidine hcl..................................64tikosyn .............................................68timolol maleate................36, 117, 118timolol maleate ophthalmic gelforming..............................117, 118tinidazole .........................................41tirosint............................................107tizanidine hcl ...........................49, 124tobi...................................................11tobradex...................................11, 115tobradex st .....................................115tobramycin sulfate...........................11tobramycin/dexamethasone...........115tobrex...............................................11tolazamide .......................................58tolbutamide......................................58tolmetin sodium.................................6tolterodine tartrate ...........................93topiramate........................................23torsemide .........................................78toviaz ...............................................93tracleer...........................................122tradjenta...........................................58tramadol hcl...................................8, 9tramadol hcl er...................................8tramadolhydrochloride/acetaminophen .......3trandolapril ......................................67tranexamic acid ...............................63transderm-scop ................................32tranylcypromine sulfate...................27travasol ..........................................134travatan z .......................................118trazodone hcl ...................................27treanda .............................................39trelstar depot mixject .................... 109trelstar la mixject .......................... 109tretinoin..................................... 40, 41trexall ............................................ 111triamcinolone acetonide.... 98, 99, 119triamcinolone in orabase................. 86triamterene/hydrochlorothiazide..... 77tribenzor.......................................... 77trifluoperazine hcl........................... 46trifluridine ....................................... 53trihexyphenidyl hcl ......................... 42tri-legest fe .................................... 104trileptal............................................ 24trilipix ............................................. 79trilyte............................................... 90trimethobenzamide hcl.................... 32trimethoprim ........................... 13, 116trimethoprim sulfate/polymyxin bsulfate........................................ 116trimipramine maleate ...................... 31trinessa .......................................... 104tri-previfem ................................... 104tri-sprintec..................................... 104trivora-28 ...................................... 104trizivir ............................................. 50trospium chloride ............................ 93trospium chloride er........................ 93truvada ............................................ 50tudorza pressair............................. 120twinject ......................................... 122twinrix........................................... 113twynsta............................................ 77tygacil ............................................. 13tykerb .............................................. 40typhim vi....................................... 113tysabri ............................................. 86tyzeka.............................................. 53tyzine............................................. 123tyzine pediatric nasal drops .......... 123Uu-cort............................................... 99uloric ............................................... 35unithroid........................................ 107ursodiol ........................................... 90Vvagifem ......................................... 102valacyclovir hcl............................... 53valcyte............................................. 49valproate sodium............................. 22valproic acid ....................................22valsartan/hydrochlorothiazide ...65, 66vancomycin hcl ...............................13vandazole.........................................13vaqta ..............................................113varivax...........................................113vectibix............................................39vectical ............................................88velcade.............................................39velivet............................................104venlafaxine hcl ..........................29, 55venlafaxine hcl er ......................29, 55ventavis..........................................122ventolin hfa....................................122veramyst ........................................119verapamil hcl...................................72verapamil hcl er...............................72veregen ............................................88vesicare............................................93vestura ...........................................104vexol..............................................117vfend iv............................................35viagra...............................................94victoza .............................................58victrelis............................................53vidaza ..............................................39videx pediatric.................................50vigamox...........................................19viibryd .............................................27vimpat........................................24, 25vincasar pfs......................................39viokace ............................................89viracept............................................52viramune..........................................50viramune xr .....................................50virazole............................................53viread.........................................50, 51vivelle-dot......................................102voltaren............................................88voriconazole ....................................35votrient ............................................40vytorin .............................................77Wwarfarin sodium...............................62welchol ............................................58Xxalkori..............................................40xarelto..............................................62xeljanz ...........................................111Page 115

xenazine...........................................85xeomin.............................................49xgeva .............................................114xifaxan.............................................13xolair..............................................124xopenex hfa ...................................122xtandi.............................................110xyrem.............................................125Yyervoy..............................................38yf-vax ............................................113Zzafirlukast......................................120zaleplon .........................................124zavesca............................................ 89zazole .............................................. 35zelapar............................................. 45zelboraf ........................................... 38zemaira.......................................... 123zemplar ......................................... 114zenpep ............................................. 89zeosa ............................................. 104zerit ................................................. 51zetia................................................. 80ziagen.............................................. 51zidovudine....................................... 51ziprasidone hcl ................................ 48zirgan .............................................. 49zithromax ........................................ 18zolinza............................................. 35zolpidem tartrate ................... 124, 125zolpidem tartrate er................124, 125zometa ...........................................114zomig.........................................36, 37zonalon ............................................88zonisamide.......................................21zortress ..........................................111zostavax.........................................113zovia 1/35e ....................................104zovia 1/50e ....................................104zovirax.............................................53zyclara .............................................88zyflo cr...........................................120zylet ...............................................116zymaxid ...........................................19zytiga .............................................110zyvox ...............................................13Page 116