Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsLEUKERAN TABS 2MG 4MATULANE CAPS 50MG 5Antiangiogenic AgentsREVLIMID CAPS 10MG 5 QL (30 EA per 30 days) PA LAREVLIMID CAPS 15MG 5 QL (21 EA per 28 days) PA LAREVLIMID CAPS 25MG 5 QL (21 EA per 28 days) PA LAREVLIMID CAPS 5MG 5 QL (30 EA per 30 days) PA LATHALOMID CAPS 100MG 5 QL (30 EA per 30 days) PATHALOMID CAPS 150MG 5 QL (60 EA per 30 days) PATHALOMID CAPS 200MG 5 QL (60 EA per 30 days) PATHALOMID CAPS 50MG 5 QL (30 EA per 30 days) PAAntiestrogens/ModifiersEMCYT CAPS 140MG 4 PAFARESTON TABS 60MG 4tamoxifen citrate tabs 10mg 1 MO GCtamoxifen citrate tabs 20mg 1 MO GCAntimetabolitesDROXIA CAPS 300MG 4GEMCITABINE HCL INJ 1GM 5hydroxyurea caps 500mg 1 MO GCTABLOID TABS 40MG 4Antineoplastics, Otheramifostine inj 500mg 1 MO GCleucovorin calcium inj 100mg 1 MO GCleucovorin calcium inj 350mg 1 MO GCleucovorin calcium tabs 10mg 1 MO GCleucovorin calcium tabs 15mg 1 MO GCleucovorin calcium tabs 25mg 1 MO GCleucovorin calcium tabs 5mg 1 MO GCLIPODOX 50 INJ 2MG/ML 5LIPODOX INJ 2MG/ML 5mitoxantrone hcl inj 2mg/ml 1 MO GCYERVOY INJ 50MG/10ML 5 PAZELBORAF TABS 240MG 5 QL (240 EA per 30 days) PAAntineoplasticsadriamycin inj 2mg/ml 2 MO GCALIMTA INJ 500MG 5ARRANON INJ 5MG/ML 5AVASTIN INJ 100MG/4ML 5 PAPA = 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 29