Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsCLINIMIX 4.25%/DEXTROSE 25% INJ 37MEQ/L; 3 B/D MO880MG/100ML; 489MG/100ML; 17MEQ/L;25GM/100ML; 438MG/100ML; 204MG/100ML;255MG/100ML; 311MG/100ML; 247MG/100ML;170MG/100ML; 238MG/100ML; 289MG/100ML;213MG/100ML; 179MG/100ML; 77MG/100ML;17MG/100ML; 247MG/100MLCLINIMIX 4.25%/DEXTROSE 5% INJ 37MEQ/L; 3 B/D MO880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML;438MG/100ML; 204MG/100ML; 255MG/100ML;311MG/100ML; 247MG/100ML; 170MG/100ML;238MG/100ML; 289MG/100ML; 213MG/100ML;179MG/100ML; 77MG/100ML; 17MG/100ML;247MG/100MLCLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML; 3 B/D MO1035MG/100ML; 575MG/100ML; 20MEQ/1000ML;15GM/100ML; 515MG/100ML; 240MG/100ML;300MG/100ML; 365MG/100ML; 290MG/100ML;200MG/100ML; 280MG/100ML; 340MG/100ML;250MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L; 3 B/D MO1035MG/100ML; 575MG/100ML; 20MEQ/L;20GM/100ML; 515MG/100ML; 240MG/100ML;300MG/100ML; 365MG/100ML; 290MG/100ML;200MG/100ML; 280MG/100ML; 340MG/100ML;250MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100MLCLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L;1035MG/100ML; 575MG/100ML; 20MEQ/L;25GM/100ML; 515MG/100ML; 240MG/100ML;300MG/100ML; 365MG/100ML; 290MG/100ML;200MG/100ML; 280MG/100ML; 340MG/100ML;250MG/100ML; 210MG/100ML; 90MG/100ML;20MG/100ML; 290MG/100ML3 B/D MOPA = 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 99