Prescription Drug Guide Comprehensive list of covered drugs

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