Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsTEKTURNA TABS 300MG 4 QL (30 EA per 30 days) STCardiovascular AgentsADVICOR TB24 20MG; 1000MG 4 QL (60 EA per 30 days)ADVICOR TB24 20MG; 500MG 4 QL (60 EA per 30 days)ADVICOR TB24 20MG; 750MG 4 QL (60 EA per 30 days)ADVICOR TB24 40MG; 1000MG 4 QL (30 EA per 30 days)ALDACTAZIDE TABS 50MG; 50MG 4amiloride/hydrochlorothiazide tabs 5mg; 50mg 1 MO GCamlodipine besylate/benazepril hcl caps 10mg; 40mg 2 MO GCamlodipine besylate/benazepril hcl caps 5mg; 40mg 2 MO GCamlodipine besylate/benazepril hydrochloride caps 2 MO GC10mg; 20mgamlodipine besylate/benazepril hydrochloride caps 2 MO GC2.5mg; 10mgamlodipine besylate/benazepril hydrochloride caps 5mg; 2 MO GC10mgamlodipine besylate/benazepril hydrochloride caps 5mg; 2 MO GC20mgAMTURNIDE TABS 150MG; 5MG; 12.5MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 10MG; 12.5MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 10MG; 25MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 5MG; 12.5MG 4 QL (30 EA per 30 days) STAMTURNIDE TABS 300MG; 5MG; 25MG 4 QL (30 EA per 30 days) STatenolol/chlorthalidone tabs 100mg; 25mg 1 MO GCatenolol/chlorthalidone tabs 50mg; 25mg 1 MO GCAZOR TABS 10MG; 20MG 3 QL (30 EA per 30 days) ST MOAZOR TABS 10MG; 40MG 3 QL (30 EA per 30 days) ST MOAZOR TABS 5MG; 20MG 3 QL (30 EA per 30 days) ST MOAZOR TABS 5MG; 40MG 3 QL (30 EA per 30 days) ST MObenazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg 1 MO GCbenazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg 1 MO GCbenazepril hcl/hydrochlorothiazide tabs 20mg; 25mg 1 MO GCbenazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg 1 MO GCBENICAR HCT TABS 12.5MG; 20MG 3 QL (30 EA per 30 days) ST MOBENICAR HCT TABS 12.5MG; 40MG 3 QL (30 EA per 30 days) ST MOBENICAR HCT TABS 25MG; 40MG 3 QL (30 EA per 30 days) ST MObisoprolol fumarate/hydrochlorothiazide tabs 10mg;6.25mg1 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 57