Prescription Drug Guide Comprehensive list of covered drugs

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