Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsDIOVAN TABS 40MG 4DIOVAN TABS 80MG 4EDARBI TABS 40MG 4 QL (30 EA per 30 days) STEDARBI TABS 80MG 4 QL (30 EA per 30 days) STeprosartan mesylate tabs 600mg 2 MO GCirbesartan tabs 150mg 2 QL (30 EA per 30 days) MO GCirbesartan tabs 300mg 2 QL (30 EA per 30 days) MO GCirbesartan tabs 75mg 2 QL (30 EA per 30 days) MO GClosartan potassium tabs 100mg 1 MO GClosartan potassium tabs 25mg 1 MO GClosartan potassium tabs 50mg 1 MO GCMICARDIS TABS 20MG 3 QL (30 EA per 30 days) MOMICARDIS TABS 40MG 3 QL (30 EA per 30 days) MOMICARDIS TABS 80MG 3 QL (30 EA per 30 days) MOvalsartan/hydrochlorothiazide tabs 12.5mg; 160mg 2valsartan/hydrochlorothiazide tabs 12.5mg; 320mg 2valsartan/hydrochlorothiazide tabs 25mg; 320mg 2Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl tabs 10mg 1 MO GCbenazepril hcl tabs 20mg 1 MO GCbenazepril hcl tabs 40mg 1 MO GCbenazepril hcl tabs 5mg 1 MO GCcaptopril tabs 100mg 1 MO GCcaptopril tabs 12.5mg 1 MO GCcaptopril tabs 25mg 1 MO GCcaptopril tabs 50mg 1 MO GCenalapril maleate tabs 10mg 1 MO GCenalapril maleate tabs 2.5mg 1 MO GCenalapril maleate tabs 20mg 1 MO GCenalapril maleate tabs 5mg 1 MO GCfosinopril sodium tabs 10mg 1 MO GCfosinopril sodium tabs 20mg 1 MO GCfosinopril sodium tabs 40mg 1 MO GClisinopril tabs 10mg 1 MO GClisinopril tabs 2.5mg 1 MO GClisinopril tabs 20mg 1 MO GClisinopril tabs 30mg 1 MO GClisinopril tabs 40mg 1 MO GClisinopril tabs 5mg 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 51