Prescription Drug Guide Comprehensive list of covered drugs

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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
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Prescription Drug GuideGuía de Med
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What is the Simply Healthcare Plans
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have two options:You can ask Member
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The information in the Requirements
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Simply Healthcare Plans, Inc.Formul
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¿Cómo uso el formulario?Hay dos m
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estricciones de uso adicional no so
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Cobertura para obtener más informa
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Drug NameDrugTier Requirements/Limi
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Page 121 and 122: IndexAabacavir ....................
Page 123 and 124: chloroquine phosphate..............
Page 125 and 126: faslodex ..........................
Page 127 and 128: linzess............................
Page 129 and 130: peganone...........................
Page 131 and 132: testosterone cypionate ............
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Prescription Drug Guide Comprehensive list of covered drugs

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