Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitscefuroxime sodium inj 750mg 2 MO GCcephalexin caps 250mg 1 MO GCcephalexin caps 500mg 1 MO GCcephalexin susr 125mg/5ml 1 MO GCcephalexin susr 250mg/5ml 1 MO GCSPECTRACEF TABS 400MG 4SUPRAX CHEW 100MG 4SUPRAX CHEW 200MG 4SUPRAX SUSR 100MG/5ML 4SUPRAX TABS 400MG 4TEFLARO INJ 400MG 4 B/DBeta-lactam, Otheraztreonam inj 1gm 2 MO GCCAYSTON SOLR 75MG 5 QL (84 ML per 28 days) PADORIBAX INJ 500MG 4imipenem/cilastatin inj 250mg; 250mg 2 MO GCimipenem/cilastatin inj 500mg; 500mg 2 MO GCINVANZ INJ 1GM 4meropenem inj 500mg 2 MO GCBeta-lactam, Penicillinsamoxicillin/clavulanate potassium er tb12 1000mg; 2 MO GC62.5mgamoxicillin/clavulanate potassium chew 200mg; 28.5mg 2 MO GCamoxicillin/clavulanate potassium chew 400mg; 57mg 2 MO GCamoxicillin/clavulanate potassium susr 250mg/5ml; 2 MO GC62.5mg/5mlamoxicillin/clavulanate potassium susr 400mg/5ml; 2 MO GC57mg/5mlamoxicillin/clavulanate potassium susr 600mg/5ml; 2 MO GC42.9mg/5mlamoxicillin/clavulanate potassium tabs 250mg; 125mg 2 MO GCamoxicillin/potassium clavulanate susr 200mg/5ml; 2 MO GC28.5mg/5mlamoxicillin/potassium clavulanate tabs 500mg; 125mg 2 MO GCamoxicillin/potassium clavulanate tabs 875mg; 125mg 2 MO GCamoxicillin caps 250mg 1 MO GCamoxicillin caps 500mg 1 MO GCamoxicillin chew 250mg 1 MO GCamoxicillin susr 125mg/5ml 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 11