Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsJAKAFI TABS 25MG 3 QL (60 EA per 30 days) PA MOJAKAFI TABS 5MG 3 QL (60 EA per 30 days) PA MOMolecular Target InhibitorsAFINITOR TABS 10MG 5 QL (60 EA per 30 days) PAAFINITOR TABS 5MG 5 QL (90 EA per 30 days) PAAFINITOR TABS 7.5MG 5 QL (30 EA per 30 days) PABOSULIF TABS 100MG 5 PABOSULIF TABS 500MG 5 PACAPRELSA TABS 100MG 5 QL (60 EA per 30 days) PA LACAPRELSA TABS 300MG 5 QL (90 EA per 90 days) PA LAGLEEVEC TABS 100MG 5 QL (90 EA per 30 days) PAGLEEVEC TABS 400MG 5 QL (60 EA per 30 days) PANEXAVAR TABS 200MG 5 QL (120 EA per 30 days) PA LASPRYCEL TABS 100MG 5 QL (60 EA per 30 days) PASPRYCEL TABS 140MG 5 QL (30 EA per 30 days) PASPRYCEL TABS 20MG 5 QL (150 EA per 30 days) PASPRYCEL TABS 50MG 5 QL (60 EA per 30 days) PASPRYCEL TABS 70MG 5 QL (60 EA per 30 days) PASPRYCEL TABS 80MG 5 QL (30 EA per 30 days) PASTIVARGA TABS 40MG 5 PASUTENT CAPS 12.5MG 5 QL (90 EA per 30 days) PASUTENT CAPS 25MG 5 QL (30 EA per 30 days) PASUTENT CAPS 50MG 5 QL (30 EA per 30 days) PATARCEVA TABS 100MG 5 QL (90 EA per 90 days) PATARCEVA TABS 150MG 5 QL (90 EA per 90 days) PATARCEVA TABS 25MG 5 QL (60 EA per 30 days) PATASIGNA CAPS 150MG 5 QL (120 EA per 30 days) PATASIGNA CAPS 200MG 5 QL (120 EA per 30 days) PATYKERB TABS 250MG 5 QL (540 EA per 90 days) PA LAVOTRIENT TABS 200MG 5 QL (360 EA per 90 days) PAXALKORI CAPS 200MG 5 QL (60 EA per 30 days) PAXALKORI CAPS 250MG 5 QL (60 EA per 30 days) PAMonoclonal AntibodiesARZERRA INJ 100MG/5ML 5 PARITUXAN INJ 10MG/ML 5 PARetinoidsPANRETIN GEL 0.1% 5 PATARGRETIN CAPS 75MG 5 PATARGRETIN GEL 1% 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 31