Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsbenztropine mesylate tabs 2mg 1 MO GCtrihexyphenidyl hcl tabs 2mg 1 MO GCtrihexyphenidyl hcl tabs 5mg 1 MO GCAntiparkinson Agents, Otheramantadine hcl caps 100mg 1 MO GCamantadine hcl syrp 50mg/5ml 1 MO GCamantadine hcl tabs 100mg 1 MO GCCOMTAN TABS 200MG 4 QL (240 EA per 30 days)entacapone tabs 200mg 2 QL (240 EA per 30 days)TASMAR TABS 100MG 5 QL (90 EA per 30 days)Antiparkinson AgentsSTALEVO 100 TABS 25MG; 200MG; 100MG 4 QL (240 EA per 30 days)STALEVO 125 TABS 31.25MG; 200MG; 125MG 4 QL (240 EA per 30 days)STALEVO 150 TABS 37.5MG; 200MG; 150MG 4 QL (240 EA per 30 days)STALEVO 200 TABS 50MG; 200MG; 200MG 4 QL (240 EA per 30 days)STALEVO 50 TABS 12.5MG; 200MG; 50MG 4 QL (240 EA per 30 days)STALEVO 75 TABS 18.75MG; 200MG; 75MG 4 QL (240 EA per 30 days)Dopamine AgonistsAPOKYN INJ 10MG/ML 5 QL (60 ML per 30 days) PA LAbromocriptine mesylate caps 5mg 2 MO GCbromocriptine mesylate tabs 2.5mg 2 MO GCpramipexole dihydrochloride tabs 0.125mg 1 MO GCpramipexole dihydrochloride tabs 0.25mg 1 MO GCpramipexole dihydrochloride tabs 0.5mg 1 MO GCpramipexole dihydrochloride tabs 0.75mg 1 MO GCpramipexole dihydrochloride tabs 1.5mg 1 MO GCpramipexole dihydrochloride tabs 1mg 1 MO GCropinirole er tb24 12mg 2 MO GCropinirole er tb24 2mg 2 MO GCropinirole er tb24 4mg 2 MO GCropinirole er tb24 6mg 2 MO GCropinirole er tb24 8mg 2 MO GCropinirole hcl tabs 0.25mg 1 MO GCropinirole hcl tabs 0.5mg 1 MO GCropinirole hcl tabs 1mg 1 MO GCropinirole hcl tabs 2mg 1 MO GCropinirole hcl tabs 3mg 1 MO GCropinirole hcl tabs 4mg 1 MO GCropinirole hcl tabs 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 33