Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsminitran pt24 0.6mg/hr 1 MO GCNITRO-BID OINT 2% 3 MOnitroglycerin transdermal pt24 0.1mg/hr 1 MO GCnitroglycerin pt24 0.2mg/hr 1 MO GCnitroglycerin pt24 0.4mg/hr 1 MO GCnitroglycerin pt24 0.6mg/hr 1 MO GCnitrolingual pumpspray soln 0.4mg/spray 2 MO GCNITROMIST AERS 400MCG/SPRAY 4NITROSTAT SUBL 0.3MG 3 MONITROSTAT SUBL 0.4MG 3 MONITROSTAT SUBL 0.6MG 3 MOVasodilators, Direct-acting Arterial/Venousisosorbide mononitrate tabs 10mg 1 MOnitroglycerin lingual aers 400mcg/spray 2nitroglycerin lingual aers 400mcg/spray 2Vasodilators, Direct-acting Arterialhydralazine hcl tabs 100mg 1 MO GChydralazine hcl tabs 10mg 1 MO GChydralazine hcl tabs 25mg 1 MO GChydralazine hcl tabs 50mg 1 MO GCminoxidil tabs 10mg 1 MO GCminoxidil tabs 2.5mg 1 MO GCCentral Nervous System AgentsAttention Deficit Hyperactivity Disorder Agents,Amphetaminesadderall xr cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg 2 QL (30 EA per 30 days) PA MOGCADDERALL XR CP24 2.5MG; 2.5MG; 2.5MG; 2.5MG 4 QL (30 EA per 30 days) PAADDERALL XR CP24 3.75MG; 3.75MG; 3.75MG; 4 QL (30 EA per 30 days) PA3.75MGADDERALL XR CP24 5MG; 5MG; 5MG; 5MG 4 QL (30 EA per 30 days) PAADDERALL XR CP24 6.25MG; 6.25MG; 6.25MG; 4 QL (30 EA per 30 days) PA6.25MGADDERALL XR CP24 7.5MG; 7.5MG; 7.5MG; 7.5MG 4 QL (30 EA per 30 days) PAamphetamine/dextroamphetamine cp24 1.25mg; 2 QL (30 EA per 30 days) PA MO1.25mg; 1.25mg; 1.25mgamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg;2.5mg; 2.5mg2 QL (30 EA per 30 days) PA MOPA = 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 63