Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsoxycodone hcl tabs 5mg 1 MO GCoxymorphone hydrochloride tabs 10mg 2 MO GCoxymorphone hydrochloride tabs 5mg 2 MO GCtramadol hcl tabs 50mg 1 MO GCAnestheticsLocal Anestheticslidocaine hcl jelly gel 2% 1 MO GClidocaine hcl jelly gel 2% 1 MO GClidocaine hcl inj 1% 1 MO GClidocaine hcl soln 4% 1 MO GClidocaine viscous soln 2% 1 MO GClidocaine/prilocaine crea 2.5%; 2.5% 2 B/D MO GClidocaine oint 5% 1 B/D MO GCLIDODERM PTCH 5% 4Anti-Addiction/ Substance Abuse Treatment AgentsAlcohol Deterrents/ Anti-cravingCAMPRAL TBEC 333MG 4disulfiram tabs 250mg 2 MO GCdisulfiram tabs 500mg 2 MO GCnaltrexone hcl tabs 50mg 2 MO GCAnti-Addiction/ Substance Abuse Treatment AgentsSUBOXONE FILM 2MG; 0.5MG 4 QL (90 EA per 30 days)SUBOXONE FILM 8MG; 2MG 4 QL (90 EA per 30 days)SUBOXONE SUBL 2MG; 0.5MG 4 QL (90 EA per 30 days)SUBOXONE SUBL 8MG; 2MG 4 QL (90 EA per 30 days)Opioid Antagonistsbuprenorphine hcl subl 2mg 2 MO GCbuprenorphine hcl subl 8mg 2 MO GCnaloxone hcl inj 1mg/ml 1 MO GCSmoking Cessation AgentsNICOTROL NS SOLN 10MG/ML 3 MOAnti-inflammatory AgentsNonsteroidal Anti-inflammatory Drugsnaproxen tabs 500mg 1 MO GCAntibacterialsAminoglycosidesamikacin sulfate inj 1gm/4ml 1 MO GCgentak oint 0.3% 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 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 7