Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsFOCALIN XR CP24 15MG 4 QL (30 EA per 30 days) PAFOCALIN XR CP24 20MG 4 QL (60 EA per 30 days) PAINTUNIV TB24 1MG 4INTUNIV TB24 2MG 4INTUNIV TB24 3MG 4INTUNIV TB24 4MG 4METADATE CD CPCR 10MG 4 QL (60 EA per 30 days) PAMETADATE CD CPCR 20MG 4 QL (60 EA per 30 days) PAMETADATE CD CPCR 60MG 4 QL (30 EA per 30 days) PAmetadate er tbcr 20mg 1 PA MO GCmethylphenidate hcl cd cpcr 10mg 2 QL (60 EA per 30 days)methylphenidate hcl cd cpcr 20mg 2 QL (60 EA per 30 days)methylphenidate hcl cd cpcr 20mg 2 QL (60 EA per 30 days)methylphenidate hcl cd cpcr 60mg 2 QL (30 EA per 30 days)methylphenidate hcl er tbcr 20mg 1 PA MO GCmethylphenidate hcl tabs 10mg 1 PA MO GCmethylphenidate hcl tabs 20mg 1 PA MO GCmethylphenidate hcl tabs 5mg 1 PA MO GCmethylphenidate hydrochloride soln 10mg/5ml 2 PA MO GCmethylphenidate hydrochloride soln 5mg/5ml 2 PA MO GCSTRATTERA CAPS 100MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 10MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 18MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 25MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 40MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 60MG 4 QL (30 EA per 30 days) PASTRATTERA CAPS 80MG 4 QL (30 EA per 30 days) PACentral Nervous System, OtherNUEDEXTA CAPS 20MG; 10MG 3 QL (60 EA per 30 days) MORILUTEK TABS 50MG 5 PAXENAZINE TABS 12.5MG 5 QL (124 EA per 25 days) PA LAXENAZINE TABS 25MG 5 QL (124 EA per 25 days) PA LAFibromyalgia AgentsSAVELLA TITRATION PACK MISC 0 3 QL (55 EA per 28 days) MOSAVELLA TABS 100MG 3 QL (60 EA per 30 days) MOSAVELLA TABS 12.5MG 3 QL (60 EA per 30 days) MOSAVELLA TABS 25MG 3 QL (60 EA per 30 days) MOSAVELLA TABS 50MG 3 QL (60 EA per 30 days) MOMultiple Sclerosis AgentsPA = 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 65