Prescription Drug Guide Comprehensive list of covered drugs

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