Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsglipizide tabs 10mg 1 QL (120 EA per 30 days) MO GCglipizide tabs 5mg 1 QL (240 EA per 30 days) MO GCglyburide micronized tabs 1.5mg 1 QL (240 EA per 30 days) MO GCglyburide micronized tabs 3mg 1 QL (120 EA per 30 days) MO GCglyburide micronized tabs 6mg 1 QL (60 EA per 30 days) MO GCglyburide tabs 1.25mg 1 QL (480 EA per 30 days) MO GCglyburide tabs 2.5mg 1 QL (240 EA per 30 days) MO GCglyburide tabs 5mg 1 QL (120 EA per 30 days) MO GCGLYSET TABS 100MG 4 QL (90 EA per 30 days)GLYSET TABS 25MG 4 QL (90 EA per 30 days)GLYSET TABS 50MG 4 QL (90 EA per 30 days)JANUVIA TABS 100MG 3 QL (30 EA per 30 days) MO GCJANUVIA TABS 25MG 3 QL (30 EA per 30 days) MO GCJANUVIA TABS 50MG 3 QL (30 EA per 30 days) MO GCmetformin hcl er tb24 500mg 1 QL (120 EA per 30 days) MO GCmetformin hcl er tb24 750mg 1 QL (60 EA per 30 days) MO GCmetformin hcl tabs 1000mg 1 QL (60 EA per 30 days) MO GCmetformin hcl tabs 500mg 1 QL (150 EA per 30 days) MO GCmetformin hcl tabs 850mg 1 QL (90 EA per 30 days) MO GCnateglinide tabs 120mg 1 QL (90 EA per 30 days) MO GCnateglinide tabs 60mg 1 QL (90 EA per 30 days) MO GCONGLYZA TABS 2.5MG 4 QL (60 EA per 30 days) GCONGLYZA TABS 5MG 4 QL (30 EA per 30 days) GCpioglitazone hcl/metformin hcl tabs 500mg; 15mg 2 MO GCpioglitazone hcl/metformin hcl tabs 850mg; 15mg 2 MO GCpioglitazone hcl tabs 15mg 2 QL (30 EA per 30 days)pioglitazone hcl tabs 30mg 2 QL (30 EA per 30 days)pioglitazone hcl tabs 45mg 2 QL (30 EA per 30 days)PRANDIN TABS 0.5MG 4 QL (120 EA per 30 days)PRANDIN TABS 1MG 4 QL (120 EA per 30 days)PRANDIN TABS 2MG 4 QL (240 EA per 30 days)SYMLINPEN 120 INJ 2700MCG/2.7ML 4SYMLINPEN 60 INJ 1500MCG/1.5ML 4tolazamide tabs 500mg 1 QL (180 EA per 30 days) MO GCtolbutamide tabs 500mg 1 QL (180 EA per 30 days) MO GCTRADJENTA TABS 5MG 3 QL (30 EA per 30 days) MOVICTOZA INJ 18MG/3ML 4 QL (18 ML per 28 days)WELCHOL PACK 3.75GM 3 MOWELCHOL TABS 625MG 3 MOPA = 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 45