Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsclarithromycin susr 250mg/5ml 2 MO GCclarithromycin tabs 250mg 2 MO GCclarithromycin tabs 500mg 2 MO GCDIFICID TABS 200MG 4 PAE.E.S. 400 TABS 400MG 3 MOE.E.S. GRANULES SUSR 200MG/5ML 3 MOERY-TAB TBEC 250MG 4ERY-TAB TBEC 333MG 4ERY-TAB TBEC 500MG 4ery pads 2% 2 MO GCERYPED 200 SUSR 200MG/5ML 4ERYPED 400 SUSR 400MG/5ML 4ERYTHROCIN STEARATE TABS 250MG 3 MOerythromycin ethylsuccinate tabs 400mg 1 MO GCerythromycin gel 2% 1 MO GCerythromycin oint 5mg/gm 1 MO GCerythromycin soln 2% 1 MO GCZITHROMAX PACK 1GM 4QuinolonesAVELOX INJ 400MG/250ML; 0.8% 4AVELOX TABS 400MG 4BESIVANCE SUSP 0.6% 4CILOXAN OINT 0.3% 4ciprofloxacin er tb24 1000mg; 0 2 MO GCciprofloxacin er tb24 500mg; 0 2 MO GCciprofloxacin hcl soln 0.3% 1 MO GCciprofloxacin hcl tabs 100mg 1 MO GCciprofloxacin hcl tabs 250mg 1 MO GCciprofloxacin hcl tabs 500mg 1 MO GCciprofloxacin hcl tabs 750mg 1 MO GCciprofloxacin inj 400mg/40ml 2 MO GCCIPRO SUSR 500MG/5ML 4FACTIVE TABS 320MG 4levofloxacin in d5w inj 5%; 500mg/100ml 1 MO GClevofloxacin inj 25mg/ml 1 MO GClevofloxacin soln 0.5% 1 MO GClevofloxacin soln 25mg/ml 1 MO GClevofloxacin tabs 250mg 1 MO GClevofloxacin tabs 500mg 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 13