Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsDEPEN TITRATABS TABS 250MG 4ELMIRON CAPS 100MG 4viagra tabs 100mg 1 QL (6 EA per 30 days) MO GCED*viagra tabs 25mg 1 QL (6 EA per 30 days) MO GCED*viagra tabs 50mg 1 QL (6 EA per 30 days) MO GCED*Phosphate Binderscalcium acetate caps 667mg 1 MO GCeliphos tabs 667mg 2 MO GCFOSRENOL CHEW 1000MG 5FOSRENOL CHEW 500MG 5PHOSLYRA SOLN 667MG/5ML 4RENVELA PACK 0.8GM 5 QL (525 EA per 30 days)RENVELA PACK 2.4GM 5 QL (180 EA per 30 days)RENVELA TABS 800MG 4Hormonal Agents, Stimulant/ Replacement/ Modifying(Adrenal)Glucocorticoids/ Mineralocorticoidsa-hydrocort inj 100mg 2 MO GCalclometasone dipropionate crea 0.05% 1 MO GCalclometasone dipropionate oint 0.05% 1 MO GCamcinonide crea 0.1% 1 MO GCamcinonide lotn 0.1% 1 MO GCaugmented betamethasone dipropionate crea 0.05% 1 MO GCaugmented betamethasone dipropionate lotn 0.05% 1 MO GCaugmented betamethasone dipropionate oint 0.05% 1 MO GCbetamethasone dipropionate crea 0.05% 1 MO GCbetamethasone dipropionate oint 0.05% 1 MO GCbetamethasone valerate crea 0.1% 1 MO GCbetamethasone valerate lotn 0.1% 1 MO GCbetamethasone valerate oint 0.1% 1 MO GCCAPEX SHAM 0.01% 4CELESTONE SOLN 0.6MG/5ML 4clobetasol propionate e crea 0.05% 1 MO GCclobetasol propionate foam 0.05% 2 MO GCclobetasol propionate gel 0.05% 1 MO GCclobetasol propionate lotn 0.05% 2 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 73