Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsEXELON SOLN 2MG/ML 4galantamine hydrobromide cp24 16mg 2 MO GCgalantamine hydrobromide cp24 24mg 2 MO GCgalantamine hydrobromide cp24 8mg 2 MO GCgalantamine hydrobromide soln 4mg/ml 2 MO GCgalantamine hydrobromide tabs 12mg 2 MO GCgalantamine hydrobromide tabs 4mg 2 MO GCgalantamine hydrobromide tabs 8mg 2 MO GCrivastigmine tartrate caps 1.5mg 2 MO GCrivastigmine tartrate caps 3mg 2 MO GCrivastigmine tartrate caps 4.5mg 2 MO GCrivastigmine tartrate caps 6mg 2 MO GCN-methyl-D-aspartate (NMDA) Receptor AntagonistNAMENDA TITRATION PAK TABS 0 3 QL (49 EA per 30 days) MONAMENDA SOLN 10MG/5ML 3 QL (300 ML per 30 days) MONAMENDA TABS 10MG 3 QL (60 EA per 30 days) MONAMENDA TABS 5MG 3 QL (60 EA per 30 days) MOAntidepressantsAntidepressants, OtherAPLENZIN TB24 174MG 4 STAPLENZIN TB24 348MG 4 STAPLENZIN TB24 522MG 4 STbudeprion sr tb12 100mg 1 MO GCbudeprion sr tb12 150mg 1 MO GCbuproban tb12 150mg 1 MO GCbupropion hcl sr tb12 200mg 1 MO GCbupropion hcl tabs 100mg 1 MO GCbupropion hcl tabs 75mg 1 MO GCFORFIVO XL TB24 450MG 4 QL (30 EA per 30 days) MOmaprotiline hcl tabs 25mg 2 MO GCmaprotiline hcl tabs 50mg 2 MO GCmaprotiline hcl tabs 75mg 2 MO GCmirtazapine odt tbdp 30mg 1 MO GCmirtazapine odt tbdp 45mg 1 MO GCmirtazapine tabs 15mg 1 MO GCmirtazapine tabs 30mg 1 MO GCmirtazapine tabs 45mg 1 MO GCmirtazapine tabs 7.5mg 1 MO GCmirtazapine tbdp 15mg 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 19