Prescription Drug Guide Comprehensive list of covered drugs
Prescription Drug Guide Comprehensive list of covered drugs
Prescription Drug Guide Comprehensive list of covered drugs
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<strong>Drug</strong> Name<strong>Drug</strong>Tier Requirements/Limitsdiflunisal tabs 500mg 1 MO GCetodolac er tb24 400mg 2 MO GCetodolac er tb24 500mg 2 MO GCetodolac er tb24 600mg 2 MO GCetodolac caps 200mg 1 MO GCetodolac caps 300mg 2etodolac caps 300mg 2etodolac caps 300mg 2etodolac tabs 400mg 1 MO GCetodolac tabs 500mg 1 MO GCfenopr<strong>of</strong>en calcium tabs 600mg 1 MO GCFLECTOR PTCH 1.3% 4flurbipr<strong>of</strong>en tabs 100mg 1 MO GCflurbipr<strong>of</strong>en tabs 50mg 1 MO GCibupr<strong>of</strong>en susp 100mg/5ml 1 MO GCibupr<strong>of</strong>en tabs 400mg 1 MO GCibupr<strong>of</strong>en tabs 600mg 1 MO GCibupr<strong>of</strong>en tabs 800mg 1 MO GCINDOCIN SUSP 25MG/5ML 4indomethacin er cpcr 75mg 1 MO GCindomethacin caps 25mg 1 MO GCindomethacin caps 50mg 1 MO GCketopr<strong>of</strong>en er cp24 200mg 2 MO GCketopr<strong>of</strong>en caps 50mg 1 MO GCketopr<strong>of</strong>en caps 75mg 1 MO GCketorolac tromethamine inj 15mg/ml 1 QL (20 ML per 30 days) PA MOGCketorolac tromethamine inj 30mg/ml 1 QL (20 ML per 30 days) PA MOGCketorolac tromethamine tabs 10mg 1 QL (20 EA per 30 days) PA MOGCmecl<strong>of</strong>enamate sodium caps 100mg 2 MO GCMECLOFENAMATE SODIUM CAPS 50MG 4mefenamic acid caps 250mg 2 MO GCmeloxicam susp 7.5mg/5ml 2 MO GCmeloxicam tabs 15mg 1 MO GCmeloxicam tabs 7.5mg 1 MO GCnabumetone tabs 500mg 1 MO GCnabumetone tabs 750mg 1 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 <strong>of</strong> 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 <strong>of</strong> Coverage for more information. ED = Excluded <strong>Drug</strong>: Thisprescription drug is not normally <strong>covered</strong> in a Medicare <strong>Prescription</strong> <strong>Drug</strong> 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 3
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