Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsINCIVEK TABS 375MG 5 QL (504 EA per 84 days) PAINTRON-A W/DILUENT INJ 10MU 4 PAINTRON-A INJ 6000000UNIT/ML 4 PAPEG-INTRON REDIPEN INJ 120MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON REDIPEN INJ 150MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON REDIPEN INJ 50MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON REDIPEN INJ 80MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEG-INTRON INJ 50MCG/0.5ML 5 QL (4 EA per 28 days) ST PAPEGASYS PROCLICK INJ 135MCG/0.5ML 5 QL (4 ML per 28 days) PAPEGASYS INJ 180MCG/0.5ML 5 QL (2 EA per 28 days) PAPEGASYS INJ 180MCG/ML 5 QL (4 ML per 28 days) PARIBAPAK TABS 400MG 5 PAribasphere caps 200mg 2 PA MO GCRIBASPHERE TABS 200MG 4 PARIBASPHERE TABS 400MG 5 PARIBASPHERE TABS 600MG 5 PAribavirin caps 200mg 2 PA MO GCribavirin tabs 200mg 2 PA MO GCSYLATRON INJ 296MCG 5 QL (4 EA per 28 days) PASYLATRON INJ 444MCG 5 QL (4 EA per 28 days) PASYLATRON INJ 888MCG 5 QL (4 EA per 28 days) PATYZEKA TABS 600MG 5 QL (30 EA per 30 days)VICTRELIS CAPS 200MG 5 QL (360 EA per 30 days) PAVIRAZOLE SOLR 6GM 5 B/DAntiherpetic Agentsacyclovir sodium inj 500mg 1 MO GCacyclovir caps 200mg 1 MO GCacyclovir susp 200mg/5ml 1 MO GCacyclovir tabs 400mg 1 MO GCacyclovir tabs 800mg 1 MO GCDENAVIR CREA 1% 4 QL (5 GM per 30 days)famciclovir tabs 125mg 2 MO GCfamciclovir tabs 250mg 2 MO GCfamciclovir tabs 500mg 2 MO GCtrifluridine soln 1% 2 MO GCvalacyclovir hcl tabs 1000mg 2 MO GCvalacyclovir hcl tabs 500mg 2 MO GCZOVIRAX CREA 5% 4 QL (15 GM per 30 days)ZOVIRAX OINT 5% 4 QL (30 GM per 30 days)PA = 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 41