Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsAnalgesicsAnalgesicsacetaminophen/caffeine/dihydrocodeine bitartrate tabs 2 QL (165 EA per 30 days) MO GC712.8mg; 60mg; 32mgacetaminophen/codeine #3 tabs 300mg; 30mg 1 QL (360 EA per 30 days) MO GCacetaminophen/codeine soln 120mg/5ml; 12mg/5ml 1 QL (3240 ML per 30 days) MOGCacetaminophen/codeine tabs 300mg; 15mg 1 QL (390 EA per 30 days) MO GCacetaminophen/codeine tabs 300mg; 60mg 1 QL (360 EA per 30 days) MO GCARTHROTEC 50 TABS 50MG; 200MCG 4ARTHROTEC 75 TABS 75MG; 200MCG 4ascomp/codeine caps 325mg; 50mg; 40mg; 30mg 2 MO GCbutalbital/acetaminophen/caffeine/codeine caps 325mg; 2 QL (180 EA per 30 days) MO GC50mg; 40mg; 30mgBUTRANS PTWK 10MCG/HR 4 QL (4 EA per 28 days)BUTRANS PTWK 20MCG/HR 4 QL (4 EA per 28 days)BUTRANS PTWK 5MCG/HR 4 QL (10 EA per 30 days)carisoprodol/aspirin/codeine tabs 325mg; 200mg; 16mg 2 PA MO GCcarisoprodol/aspirin tabs 325mg; 200mg 2 PA MO GCco-gesic tabs 500mg; 5mg 1 QL (240 EA per 30 days) MO GCendocet tabs 325mg; 10mg 2 QL (360 EA per 30 days) MO GCendocet tabs 325mg; 5mg 1 QL (360 EA per 30 days) MO GCendocet tabs 325mg; 7.5mg 2 QL (360 EA per 30 days) MO GCendocet tabs 500mg; 7.5mg 2 QL (240 EA per 30 days) MO GCendocet tabs 650mg; 10mg 2 QL (180 EA per 30 days) MO GCendodan tabs 325mg; 4.835mg 1 MO GChydrocodone bitartrate/acetaminophen soln325mg/15ml; 7.5mg/15ml1 QL (5520 ML per 30 days) MOGChydrocodone bitartrate/acetaminophen tabs 300mg; 1 QL (180 EA per 30 days) MO GC10mghydrocodone bitartrate/acetaminophen tabs 300mg; 5mg1 QL (360 EA per 30 days) MO GChydrocodone bitartrate/acetaminophen tabs 750mg; 1 QL (150 EA per 30 days) MO GC10mghydrocodone/acetaminophen soln 500mg/15ml;7.5mg/15ml1 QL (3600 ML per 30 days) MOGChydrocodone/acetaminophen tabs 325mg; 10mg 1 QL (180 EA per 30 days) MO GChydrocodone/acetaminophen tabs 325mg; 5mg 1 QL (360 EA per 30 days) MO GChydrocodone/acetaminophen tabs 325mg; 7.5mg 1 QL (240 EA per 30 days) MO GChydrocodone/acetaminophen tabs 500mg; 10mg 1 QL (180 EA per 30 days) 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 1