Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsclindamycin phosphate soln 1% 1 MO GCclindamycin phosphate swab 1% 1 MO GCCUBICIN INJ 500MG 5LINCOCIN INJ 300MG/ML 3 MOMACRODANTIN CAPS 25MG 4 PAmethenamine hippurate tabs 1gm 2 MO GCMETROGEL GEL 1% 4metronidazole in nacl 0.79% inj 500mg/100ml; 0.79% 2 MO GCmetronidazole vaginal gel 0.75% 1 MO GCmetronidazole caps 375mg 2 MO GCmetronidazole crea 0.75% 1 MO GCmetronidazole gel 0.75% 1 MO GCmetronidazole lotn 0.75% 1 MO GCmetronidazole tabs 250mg 1 MO GCmetronidazole tabs 500mg 1 MO GCMONUROL PACK 5.631GM 4mupirocin oint 2% 1 MO GCnitrofurantoin macrocrystalline caps 50mg 2 PA MO GCnitrofurantoin monohydrate caps 100mg 2 PA MO GCNITROFURANTOIN SUSP 25MG/5ML 4SSD CREA 1% 3SULFAMYLON CREA 85MG/GM 4THERMAZENE CREA 1% 3trimethoprim tabs 100mg 1 MO GCTYGACIL INJ 50MG 4VANCOMYCIN HCL CAPS 125MG 5VANCOMYCIN HCL CAPS 250MG 5vancomycin hcl inj 1000mg 2 B/D MO GCvancomycin hcl inj 10gm 2 B/D MO GCvancomycin hcl inj 500mg 2 B/D MO GCvandazole gel 0.75% 1 MO GCXIFAXAN TABS 200MG 4 QL (9 EA per 30 days)XIFAXAN TABS 550MG 5 QL (60 EA per 30 days)ZYVOX INJ 2MG/ML 5 PAZYVOX SUSR 100MG/5ML 5 QL (1800 ML per 30 days) PAZYVOX TABS 600MG 5 QL (56 EA per 30 days) PAAntibacterialsCOLISTIMETHATE SODIUM INJ 150MG 4 B/DSYNERCID INJ 350MG; 150MG 5PA = 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 9