Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsLAMICTAL ODT TBDP 200MG 4 QL (30 EA per 30 days)LAMICTAL ODT TBDP 25MG 4 QL (60 EA per 30 days)LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE4 QL (49 EA per 30 days)KIT 0LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT 4 QL (98 EA per 30 days)TAKING VALPROATE KIT 0LAMICTAL STARTER/TAKING VALPROATE KIT 25MG 4 QL (35 EA per 30 days)LAMICTAL XR KIT 0 4 QL (35 EA per 35 days)LAMICTAL XR TB24 100MG 4 QL (60 EA per 30 days)LAMICTAL XR TB24 200MG 4 QL (90 EA per 30 days)LAMICTAL XR TB24 250MG 4 QL (30 EA per 30 days)LAMICTAL XR TB24 25MG 4 QL (60 EA per 30 days)LAMICTAL XR TB24 50MG 4 QL (60 EA per 30 days)lamotrigine chew 25mg 1 MO GClamotrigine chew 5mg 1 MO GClamotrigine tabs 100mg 1 MO GClamotrigine tabs 150mg 1 MO GClamotrigine tabs 200mg 1 MO GClamotrigine tabs 25mg 1 MO GCtopiramate cpsp 15mg 1 MO GCtopiramate cpsp 25mg 1 MO GCtopiramate tabs 100mg 1 MO GCtopiramate tabs 200mg 1 MO GCtopiramate tabs 25mg 1 MO GCtopiramate tabs 50mg 1 MO GCSodium Channel AgentsBANZEL SUSP 40MG/ML 5 QL (2400 ML per 30 days)BANZEL TABS 200MG 4 QL (60 EA per 30 days)BANZEL TABS 400MG 5 QL (240 EA per 30 days)carbamazepine er tb12 200mg 2 MOcarbamazepine er tb12 400mg 2 MOcarbamazepine chew 100mg 1 MO GCcarbamazepine susp 100mg/5ml 1 MO GCDILANTIN INFATABS CHEW 50MG 4DILANTIN CAPS 100MG 4DILANTIN CAPS 30MG 4DILANTIN SUSP 125MG/5ML 4epitol tabs 200mg 1 MO GCEQUETRO CP12 100MG 4PA = 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 17