Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsclorazepate dipotassium tabs 15mg 2 QL (90 EA per 30 days) PA MOGCclorazepate dipotassium tabs 3.75mg 2 QL (90 EA per 30 days) PA MOGCclorazepate dipotassium tabs 7.5mg 2 QL (90 EA per 30 days) PA MOGCDIAZEPAM GEL 10MG 4 PAdiazepam soln 1mg/ml 1 QL (1200 ML per 30 days) PAMO GCdiazepam tabs 10mg 1 QL (120 EA per 30 days) PA MOGCdiazepam tabs 2mg 1 QL (60 EA per 30 days) PA MOGCdiazepam tabs 5mg 1 QL (60 EA per 30 days) PA MOGClorazepam intensol conc 2mg/ml 2 QL (45 ML per 30 days) MO GClorazepam tabs 0.5mg 2 QL (180 EA per 30 days) MO GClorazepam tabs 1mg 2 QL (90 EA per 30 days) MO GClorazepam tabs 2mg 2 QL (30 EA per 30 days) MO GCmeprobamate tabs 200mg 2 PA MO GCmeprobamate tabs 400mg 2 PA MO GCtemazepam caps 15mg 2 QL (30 EA per 30 days) MO GCtemazepam caps 30mg 2 QL (30 EA per 30 days) MO GCSSRIs/ SNRIsvenlafaxine hcl er cp24 150mg 1 MO GCvenlafaxine hcl er cp24 37.5mg 1 MO GCvenlafaxine hcl er cp24 75mg 1 MO GCBipolar AgentsMood Stabilizerscarbamazepine er cp12 100mg 2 MO GCcarbamazepine er cp12 200mg 2 MO GCcarbamazepine er cp12 300mg 2 MO GClithium carbonate er tbcr 300mg 1 MO GClithium carbonate er tbcr 450mg 1 MO GClithium carbonate caps 150mg 1 MO GClithium carbonate caps 300mg 1 MO GClithium carbonate caps 600mg 1 MO GClithium carbonate tabs 300mg 1 MO GClithium citrate soln 8meq/5ml 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 43