Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitslevetiracetam er tb24 750mg 2 MO GClevetiracetam inj 500mg/5ml 2 MO GClevetiracetam soln 100mg/ml 1 MO GClevetiracetam tabs 1000mg 1 MO GClevetiracetam tabs 250mg 1 MO GClevetiracetam tabs 500mg 1 MO GClevetiracetam tabs 750mg 1 MO GCONFI TABS 10MG 4 QL (60 EA per 30 days)ONFI TABS 20MG 4 QL (60 EA per 30 days)ONFI TABS 5MG 4 QL (60 EA per 30 days)phenobarbital elix 20mg/5ml 1 QL (1500 ML per 30 days) PAMO GCphenobarbital tabs 100mg 1 QL (90 EA per 30 days) PA MOphenobarbital tabs 15mg 1 QL (90 EA per 30 days) PA MOphenobarbital tabs 16.2mg 1 QL (90 EA per 30 days) PA MOGCphenobarbital tabs 30mg 1 QL (90 EA per 30 days) PA MOGCphenobarbital tabs 32.4mg 1 QL (30 EA per 30 days) PA MOGCphenobarbital tabs 60mg 1 QL (90 EA per 30 days) PA MOphenobarbital tabs 64.8mg 1 QL (90 EA per 30 days) PA MOGCphenobarbital tabs 97.2mg 1 QL (90 EA per 30 days) PA MOGCPOTIGA TABS 200MG 5 PAPOTIGA TABS 300MG 5 PAPOTIGA TABS 400MG 5 PAPOTIGA TABS 50MG 5 PACalcium Channel Modifying AgentsCELONTIN CAPS 300MG 4ethosuximide caps 250mg 2 MO GCethosuximide soln 250mg/5ml 2 MO GCLYRICA CAPS 100MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 150MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 200MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 225MG 3 QL (60 EA per 30 days) MOLYRICA CAPS 25MG 3 QL (90 EA per 30 days) MOLYRICA CAPS 300MG 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 15