Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsmetolazone tabs 5mg 1 MO GCTHALITONE TABS 15MG 4Dyslipidemics, Fibric Acid DerivativesANTARA CAPS 130MG 3 ST MOANTARA CAPS 43MG 3 ST MOfenofibrate micronized caps 134mg 1 MO GCfenofibrate micronized caps 200mg 1 MO GCfenofibrate micronized caps 67mg 1 MO GCfenofibrate tabs 145mg 2 MOfenofibrate tabs 160mg 1 MO GCfenofibrate tabs 48mg 2 MOfenofibrate tabs 54mg 1 MO GCFENOGLIDE TABS 120MG 4 STFENOGLIDE TABS 40MG 4 STgemfibrozil tabs 600mg 1 QL (60 EA per 30 days) MO GCLIPOFEN CAPS 150MG 3 ST MOLOFIBRA TABS 160MG 4 STNALFON CAPS 400MG 4TRILIPIX CPDR 135MG 4 STTRILIPIX CPDR 45MG 4 STDyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium tabs 10mg 2 MO GCatorvastatin calcium tabs 20mg 2 MO GCatorvastatin calcium tabs 40mg 2 MO GCatorvastatin calcium tabs 80mg 2 MO GCCRESTOR TABS 10MG 3 QL (30 EA per 30 days) MOCRESTOR TABS 20MG 3 QL (30 EA per 30 days) MOCRESTOR TABS 40MG 3 QL (30 EA per 30 days) MOCRESTOR TABS 5MG 3 QL (30 EA per 30 days) MOfluvastatin caps 20mg 2 QL (30 EA per 30 days) MO GCfluvastatin caps 40mg 2 QL (60 EA per 30 days) MO GCLESCOL XL TB24 80MG 4 QL (30 EA per 30 days) STLIVALO TABS 1MG 4 QL (30 EA per 30 days) STLIVALO TABS 2MG 4 QL (30 EA per 30 days) STLIVALO TABS 4MG 4 QL (30 EA per 30 days) STlovastatin tabs 10mg 1 MO GClovastatin tabs 20mg 1 MO GClovastatin tabs 40mg 1 MO GCpravastatin sodium tabs 10mg 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 61