Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsSerotonin/ Norepinephrine Reuptake Inhibitorscitalopram hydrobromide soln 10mg/5ml 1 MO GCcitalopram hydrobromide tabs 10mg 1 MO GCcitalopram hydrobromide tabs 20mg 1 MO GCcitalopram hydrobromide tabs 40mg 1 MO GCCYMBALTA CPEP 20MG 4 QL (60 EA per 30 days) STCYMBALTA CPEP 30MG 4 QL (60 EA per 30 days) STCYMBALTA CPEP 60MG 4 QL (30 EA per 30 days) STescitalopram oxalate soln 5mg/5ml 2 QL (600 ML per 30 days) MO GCescitalopram oxalate tabs 10mg 2 MO GCescitalopram oxalate tabs 20mg 2 QL (30 EA per 30 days) MO GCescitalopram oxalate tabs 5mg 2 QL (30 EA per 30 days) MO GCfluoxetine hcl caps 10mg 1 MO GCfluoxetine hcl caps 20mg 1 MO GCfluoxetine hcl caps 40mg 1 MO GCfluoxetine hcl soln 20mg/5ml 1 MO GCfluoxetine hcl tabs 10mg 1 MO GCfluoxetine hcl tabs 20mg 1 MO GCfluvoxamine maleate tabs 100mg 1 MO GCfluvoxamine maleate tabs 25mg 1 MO GCfluvoxamine maleate tabs 50mg 1 MO GCparoxetine hcl er tb24 12.5mg 2 MO GCparoxetine hcl er tb24 25mg 2 MO GCparoxetine hcl er tb24 37.5mg 2 MO GCparoxetine hcl tabs 10mg 1 MO GCparoxetine hcl tabs 20mg 1 MO GCparoxetine hcl tabs 30mg 1 MO GCparoxetine hcl tabs 40mg 1 MO GCPAXIL SUSP 10MG/5ML 4 STPEXEVA TABS 20MG 4 QL (30 EA per 30 days) STPEXEVA TABS 40MG 4 QL (30 EA per 30 days) STPRISTIQ TB24 100MG 4 QL (30 EA per 30 days) STPRISTIQ TB24 50MG 4 QL (30 EA per 30 days) STsertraline hcl conc 20mg/ml 1 MO GCsertraline hcl tabs 100mg 1 MO GCsertraline hcl tabs 25mg 1 MO GCsertraline hcl tabs 50mg 1 MO GCVENLAFAXINE HCL ER TB24 150MG 4 STVENLAFAXINE HCL ER TB24 225MG 4 STPA = 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 21