Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsdiltiazem cd cp24 240mg 1 MO GCdiltiazem cd cp24 300mg 1 MO GCdiltiazem hcl er cp12 120mg 1 MO GCdiltiazem hcl er cp12 60mg 1 MO GCdiltiazem hcl er cp12 90mg 1 MO GCdiltiazem hcl er cp24 180mg 1 MO GCdiltiazem hcl er cp24 360mg 1 MO GCdiltiazem hcl tabs 120mg 1 MO GCdiltiazem hcl tabs 30mg 1 MO GCdiltiazem hcl tabs 60mg 1 MO GCdiltiazem hcl tabs 90mg 1 MO GCDYNACIRC CR TB24 10MG 4 QL (60 EA per 30 days)DYNACIRC CR TB24 5MG 4 QL (30 EA per 30 days)EXFORGE HCT TABS 10MG; 12.5MG; 160MG 4 MOEXFORGE HCT TABS 10MG; 25MG; 160MG 4 MOEXFORGE HCT TABS 10MG; 25MG; 320MG 4 MOEXFORGE HCT TABS 5MG; 12.5MG; 160MG 4 MOEXFORGE HCT TABS 5MG; 25MG; 160MG 4 MOEXFORGE TABS 10MG; 160MG 4 MOEXFORGE TABS 10MG; 320MG 4 MOEXFORGE TABS 5MG; 160MG 4 MOEXFORGE TABS 5MG; 320MG 4 MOfelodipine er tb24 10mg 1 MO GCfelodipine er tb24 2.5mg 1 MO GCfelodipine er tb24 5mg 1 MO GCisradipine caps 2.5mg 2 MO GCisradipine caps 5mg 2 MO GCmatzim la tb24 180mg 2 MO GCmatzim la tb24 240mg 2 MO GCmatzim la tb24 300mg 2 MO GCmatzim la tb24 360mg 2 MO GCmatzim la tb24 420mg 2 MO GCnicardipine hcl caps 20mg 1 MO GCnicardipine hcl caps 30mg 1 MO GCnifediac cc tb24 90mg 1 MO GCnifedical xl tb24 30mg 1 MO GCnifedical xl tb24 60mg 1 MO GCnifedipine er tb24 30mg 1 MO GCnifedipine er tb24 60mg 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 55