Prescription Drug Guide Comprehensive list of covered drugs

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course of action for you, we may cover your drug in certain cases during the first 90 days you are amember of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we willcover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go toa network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you havebeen a member of the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill your prescription until wehave provided you with a 93-day transition supply, consistent with the dispensing increment, (unlessyou have a prescription written for fewer days). We will cover more than one refill of these drugs for thefirst 90 days you are a member of our plan. If you need a drug that is not on our formulary or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while youpursue a formulary exception.For current members who are changing from one treatment setting to another, for example entering along- term care facility from a hospital or being discharged from a hospital to home, the member andprovider will need to utilize our exception and appeals process should the drugs not be on our formulary.Members entering or being discharged from a long-term care facility will be allowed a one-timeemergency supply of a 31-day supply for medications which the member has not already received atransition supply. In addition, the dispensing pharmacist will need to call the Pharmacy Help Desk toreceive appropriate directions to dispense a prescription required due to a level of care change.For more informationFor more detailed information about your Simply Healthcare Plans, Inc. prescription drug coverage,please review your Evidence of Coverage and other plan materials.If you have questions about Simply Healthcare Plans, Inc., please call Member Services at 1-877-577-0115. If you use a TTY device, please call 711. We are open 7 days a week, 8 a.m. to 8 p.m. FromFebruary 15 th until September 30 th , you may leave us a voice mail message after hours, Saturdays,Sundays and holidays, and we will return your call the next business day. Or visitwww.mysimplymedicare.com.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.Simply Healthcare Plans, Inc.’s FormularyThe formulary below provides coverage information about some of the drugs covered by SimplyHealthcarePlans, Inc. If you have trouble finding your drug in the list, turn to the Index that begins on page 53.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR 10MG) and generic drugs are listed in lower-case italics (e.g., pravastatin sodium 10 mg).v
The information in the Requirements/Limits column tells you if Simply Healthcare Plans, Inc. has anyspecial requirements for coverage of your drug.List of AbbreviationsB/DEDGCGC DLAMOPAQLSTThis prescription drug has a Part B versus D administrative prior authorization requirement. Thisdrug may be covered under Medicare Part B or D depending upon the circumstances.Information may need to be submitted describing the use and setting of the drug to make thedetermination.This prescription drug is not normally covered in a Medicare Prescription Drug Plan. Theamount you pay when you fill a prescription for this drug does not count towards your total drugcosts (that is, the amount you pay does not help you qualify for catastrophic coverage). Inaddition, if you are receiving extra help to pay for your prescriptions, you will not get any extrahelp to pay for this drug.Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.Please refer to our Evidence of Coverage for more information about this coverage.Additional Gap Coverage for specific plans. We provide additional coverage of this prescriptiondrug in the coverage gap. Please refer to our Evidence of Coverage for more information aboutthis coverage.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.Mail Order Drug. This prescription drug is available through a mail-order service.Prior Authorization. Simply Healthcare Plans, Inc. requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from SimplyHealthcare Plans, Inc. before you fill your prescriptions. If you don't get approval, SimplyHealthcare Plans, Inc. may not cover the drug.Quantity Limit. For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drugthat Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.provides 30 tablets per prescription for Celebrex 100mg Capsules. This may be in addition to astandard one month or three month supply.Step Therapy. In some cases, Simply Healthcare Plans, Inc requires you to first try certain drugsto treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Incmay not cover drug B unless you try Drug A first. If Drug A does not work for you, SimplyHealthcare Plans, Inc will then cover Drug.vi
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IndexAabacavir ....................
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chloroquine phosphate..............
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faslodex ..........................
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linzess............................
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peganone...........................
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testosterone cypionate ............
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Prescription Drug Guide Comprehensive list of covered drugs

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