Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsHUMULIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 3 GCHUMULIN N U-100 PEN INJ 100UNIT/ML 3 GCHUMULIN N INJ 100UNIT/ML 3 GCHUMULIN R U-500 (CONCENTRATED) INJ 3 GC500UNIT/MLHUMULIN R INJ 100UNIT/ML 3 GCLANTUS SOLOSTAR INJ 100UNIT/ML 3 GCLANTUS INJ 100UNIT/ML 3 MO GCLEVEMIR FLEXPEN INJ 100UNIT/ML 3LEVEMIR INJ 100UNIT/ML 3NOVOLIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 3 GCNOVOLIN N INJ 100UNIT/ML 3 GCNOVOLIN R INJ 100UNIT/ML 3 GCNOVOLOG FLEXPEN INJ 100UNIT/ML 3 GCNOVOLOG MIX 70/30 PREFILLED FLEXPEN INJ 3 GC30UNIT/ML; 70UNIT/MLNOVOLOG MIX 70/30 INJ 30UNIT/ML; 70UNIT/ML 3 GCNOVOLOG INJ 100UNIT/ML 3 GCBlood Products/ Modifiers/ Volume ExpandersAnticoagulantsCOUMADIN TABS 10MG 4COUMADIN TABS 1MG 4COUMADIN TABS 2.5MG 4COUMADIN TABS 2MG 4COUMADIN TABS 3MG 4COUMADIN TABS 4MG 4COUMADIN TABS 5MG 4COUMADIN TABS 6MG 4COUMADIN TABS 7.5MG 4ENOXAPARIN SODIUM INJ 100MG/ML 5 QL (28 ML per 30 days)ENOXAPARIN SODIUM INJ 120MG/0.8ML 5 QL (28 ML per 30 days)ENOXAPARIN SODIUM INJ 150MG/ML 5 QL (28 ML per 30 days)enoxaparin sodium inj 30mg/0.3ml 2 QL (28 ML per 30 days) MO GCenoxaparin sodium inj 40mg/0.4ml 2 QL (28 ML per 30 days) MO GCenoxaparin sodium inj 60mg/0.6ml 2 QL (28 ML per 30 days) MO GCENOXAPARIN SODIUM INJ 80MG/0.8ML 4 QL (28 ML per 30 days)FONDAPARINUX SODIUM INJ 10MG/0.8ML 5 QL (14 ML per 28 days)FONDAPARINUX SODIUM INJ 2.5MG/0.5ML 4 QL (14 ML per 28 days)FONDAPARINUX SODIUM INJ 5MG/0.4ML 5 QL (14 ML per 28 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 47