Prescription Drug Guide Comprehensive list of covered drugs

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