Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsCARAC CREA 0.5% 4claravis caps 10mg 2 MO GCclaravis caps 20mg 2 MO GCCLARAVIS CAPS 30MG 5claravis caps 40mg 2 MO GCclindamycin/benzoyl peroxide gel 5%; 1% 2 MO GCclotrimazole/betamethasone dipropionate crea 0.05%; 1 MO GC1%clotrimazole/betamethasone dipropionate lotn 0.05%; 1 MO GC1%CONDYLOX GEL 0.5% 4CORTISPORIN CREA 0.5%; 0.5%; 10000UNIT/GM 4CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%; 45000UNIT/GMDOVONEX CREA 0.005% 4ELIDEL CREA 1% 4 QL (100 GM per 30 days)erythromycin/benzoyl peroxide gel 5%; 3% 2 MO GCFINACEA GEL 15% 4FLUOROPLEX CREA 1% 4fluorouracil crea 5% 2 MO GCfluorouracil inj 2.5gm/50ml 2 MO GCfluorouracil soln 2% 2fluorouracil soln 5% 2imiquimod crea 5% 1 MO GClaclotion lotn 12% 1 MO GCnystatin/triamcinolone crea 100000unit/gm; 0.1% 1 MO GCnystatin/triamcinolone oint 100000unit/gm; 0.1% 1 MO GCOXSORALEN ULTRA CAPS 10MG 4PHISOHEX LIQD 3% 3 MOpodofilox soln 0.5% 1 MO GCPROTOPIC OINT 0.03% 4 QL (100 GM per 30 days)PROTOPIC OINT 0.1% 4 QL (60 GM per 30 days)REGRANEX GEL 0.01% 5 QL (30 GM per 30 days) PASANTYL OINT 250UNIT/GM 4selenium sulfide lotn 2.5% 2 MO GCSOLARAZE GEL 3% 4SORIATANE CAPS 10MG 5 QL (60 EA per 30 days) PASORIATANE CAPS 17.5MG 5 QL (60 EA per 30 days) PASORIATANE CAPS 25MG 5 QL (60 EA per 30 days) PAPA = 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 67