Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsdoxepin hcl conc 10mg/ml 1 MO GCimipramine hcl tabs 10mg 1 MO GCimipramine hcl tabs 25mg 1 MO GCimipramine hcl tabs 50mg 1 MO GCimipramine pamoate caps 100mg 2 MO GCIMIPRAMINE PAMOATE CAPS 125MG 4 QL (30 EA per 30 days)imipramine pamoate caps 150mg 2 MO GCimipramine pamoate caps 75mg 2 MO GCnortriptyline hcl caps 10mg 1 MO GCnortriptyline hcl caps 25mg 1 MO GCnortriptyline hcl caps 50mg 1 MO GCnortriptyline hcl caps 75mg 1 MO GCprotriptyline hcl tabs 10mg 2 MO GCprotriptyline hcl tabs 5mg 2 MO GCSILENOR TABS 3MG 4SILENOR TABS 6MG 4trimipramine maleate caps 100mg 2 MO GCtrimipramine maleate caps 25mg 2 MO GCtrimipramine maleate caps 50mg 2 MO GCAntiemeticsAntiemetics, Otherchlorpromazine hcl inj 25mg/ml 1 MO GCchlorpromazine hcl tabs 100mg 1 MO GCchlorpromazine hcl tabs 10mg 1 MO GCchlorpromazine hcl tabs 200mg 1 MO GCchlorpromazine hcl tabs 25mg 1 MO GCchlorpromazine hcl tabs 50mg 1 MO GCcompro supp 25mg 1 MO GCdiphenhydramine hcl caps 50mg 1 PA MO GChydroxyzine hcl inj 25mg/ml 1 PA MO GChydroxyzine hcl inj 50mg/ml 1 PA MO GChydroxyzine hcl soln 10mg/5ml 1 PA MO GChydroxyzine hcl tabs 10mg 1 PA MO GChydroxyzine hcl tabs 25mg 1 PA MO GChydroxyzine hcl tabs 50mg 1 PA MO GChydroxyzine pamoate caps 100mg 1 PA MO GChydroxyzine pamoate caps 25mg 1 PA MO GChydroxyzine pamoate caps 50mg 1 PA MO GCmeclizine hcl tabs 12.5mg 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 23