Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsterconazole crea 0.8% 1terconazole supp 80mg 1 MO GCVFEND IV INJ 200MG 4 PAvoriconazole inj 200mg 2 PAVORICONAZOLE TABS 200MG 5 QL (60 EA per 30 days) PAVORICONAZOLE TABS 50MG 5 QL (120 EA per 30 days) PAzazole crea 0.4% 1 MO GCzazole crea 0.8% 1 MO GCZOLINZA CAPS 100MG 5 QL (120 EA per 30 days) PAAntigout AgentsAntigout Agentsallopurinol tabs 100mg 1 MO GCallopurinol tabs 300mg 1 MO GCCOLCRYS TABS 0.6MG 4 QL (120 EA per 30 days)probenecid/colchicine tabs 0.5mg; 500mg 1 MO GCprobenecid tabs 500mg 1 MO GCULORIC TABS 40MG 4 PAULORIC TABS 80MG 4 PAAntimigraine AgentsErgot Alkaloidsdihydroergotamine mesylate inj 1mg/ml 2 MO GCMIGERGOT SUPP 100MG; 2MG 4MIGRANAL SOLN 4MG/ML 5 QL (12 ML per 30 days)ProphylacticBOTOX INJ 100UNIT 4 PAtimolol maleate tabs 10mg 1 MO GCtimolol maleate tabs 20mg 1 MO GCtimolol maleate tabs 5mg 1 MO GCSerotonin (5-HT) 1b/1d Receptor AgonistsAXERT TABS 12.5MG 4 QL (24 EA per 28 days)FROVA TABS 2.5MG 4 QL (12 EA per 30 days)IMITREX SOLN 20MG/ACT 4IMITREX SOLN 5MG/ACT 4MAXALT-MLT TBDP 10MG 4 QL (12 EA per 30 days)MAXALT-MLT TBDP 5MG 4 QL (12 EA per 30 days)MAXALT TABS 10MG 4 QL (12 EA per 30 days)MAXALT TABS 5MG 4 QL (12 EA per 30 days)naratriptan hcl tabs 1mg 1 MO GCnaratriptan hcl tabs 2.5mg 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 27