Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsARANESP ALBUMIN FREE INJ 100MCG/ML 5 QL (4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 200MCG/ML 5 QL (1.6 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 25MCG/ML 4 QL (4 ML per 30 days) ST PAARANESP ALBUMIN FREE INJ 300MCG/0.6ML 5 QL (2.4 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 40MCG/ML 4 QL (3.2 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 500MCG/ML 5 QL (1 ML per 28 days) ST PAARANESP ALBUMIN FREE INJ 60MCG/ML 4 QL (2.4 ML per 28 days) ST PALEUKINE INJ 250MCG 5 PANEULASTA INJ 6MG/0.6ML 5 PANEUPOGEN INJ 300MCG/0.5ML 5 PANEUPOGEN INJ 480MCG/0.8ML 5 PANEUPOGEN INJ 480MCG/1.6ML 5 PAPROCRIT INJ 10000UNIT/ML 4 QL (12 ML per 30 days) PAPROCRIT INJ 20000UNIT/ML 5 QL (12 ML per 30 days) PAPROCRIT INJ 2000UNIT/ML 4 QL (12 ML per 30 days) PAPROCRIT INJ 3000UNIT/ML 4 QL (12 ML per 30 days) PAPROCRIT INJ 40000UNIT/ML 5 QL (12 ML per 30 days) PAPROCRIT INJ 4000UNIT/ML 4 QL (12 ML per 30 days) PAPROMACTA TABS 12.5MG 5 QL (30 EA per 30 days) PAPROMACTA TABS 25MG 5 QL (30 EA per 30 days) PAPROMACTA TABS 50MG 5 QL (30 EA per 30 days) PAPROMACTA TABS 75MG 5 QL (30 EA per 30 days) PABlood Products/ Modifiers/ Volume ExpandersCINRYZE INJ 500UNIT 5 PANEUMEGA INJ 5MG 5 PACoagulantstranexamic acid inj 100mg/ml 2 MO GCPlatelet Modifying AgentsAGGRENOX CP12 25MG; 200MG 4 QL (60 EA per 30 days)cilostazol tabs 100mg 1 MO GCcilostazol tabs 50mg 1 MO GCclopidogrel tabs 300mg 2 MO GCclopidogrel tabs 75mg 2 QL (34 EA per 30 days) MO GCdipyridamole tabs 25mg 1 PA MO GCdipyridamole tabs 50mg 1 PA MO GCdipyridamole tabs 75mg 1 PA MO GCEFFIENT TABS 10MG 4 QL (36 EA per 30 days)EFFIENT TABS 5MG 4 QL (43 EA per 30 days)ticlopidine hcl tabs 250mg 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 49