Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsfentanyl pt72 12mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 25mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 50mcg/hr 2 QL (15 EA per 30 days) MO GCfentanyl pt72 75mcg/hr 2 QL (15 EA per 30 days) MO GCFENTORA TABS 200MCG 5 QL (120 EA per 30 days) ST PAFENTORA TABS 400MCG 5 QL (120 EA per 30 days) ST PAFENTORA TABS 800MCG 5 QL (120 EA per 30 days) ST PAmethadone hcl soln 5mg/5ml 1 MO GCmethadone hcl tabs 10mg 1 MO GCmethadone hcl tabs 5mg 1 MO GCmorphine sulfate er cp24 100mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 20mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 30mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 50mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 60mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er cp24 80mg 2 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 100mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 15mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 200mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 30mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate er tb12 60mg 1 QL (60 EA per 30 days) MO GCmorphine sulfate soln 10mg/5ml 1 MO GCmorphine sulfate soln 20mg/5ml 1 MO GCmorphine sulfate soln 20mg/ml 1 MO GCmorphine sulfate tabs 15mg 1 MO GCmorphine sulfate tabs 30mg 1 MO GCMS CONTIN TB12 100MG 4 QL (60 EA per 30 days)MS CONTIN TB12 15MG 4 QL (60 EA per 30 days)MS CONTIN TB12 30MG 4 QL (60 EA per 30 days)MS CONTIN TB12 60MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 100MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 150MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 200MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 250MG 4 QL (60 EA per 30 days)NUCYNTA ER TB12 50MG 4 QL (300 EA per 30 days)ONSOLIS FILM 200MCG 5 QL (120 EA per 30 days) ST PAONSOLIS FILM 400MCG 5 QL (90 EA per 30 days) ST PAOPANA ER (CRUSH RESISTANT) TB12 10MG 3 QL (60 EA per 30 days) MOOPANA ER (CRUSH RESISTANT) TB12 20MG 3 QL (60 EA per 30 days) 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 5