Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/LimitsHormonal Agents, Stimulant/ Replacement/ Modifying (SexHormones/ Modifiers)Anabolic SteroidsOXANDROLONE TABS 10MG 5 PAoxandrolone tabs 2.5mg 2 PA MO GCAndrogensANDROGEL PUMP GEL 1.62% 3 PA MOANDROGEL GEL 50MG/5GM 3 PA MOANDROXY TABS 10MG 4danazol caps 100mg 2 MO GCdanazol caps 200mg 2 MO GCdanazol caps 50mg 2 MO GCMETHITEST TABS 10MG 3 MOSTRIANT MISC 30MG 4 QL (60 EA per 30 days) ST PAtestosterone cypionate inj 100mg/ml 1 PA MO GCtestosterone cypionate inj 200mg/ml 1 PA MO GCtestosterone enanthate inj 200mg/ml 1 PA MO GCTESTRED CAPS 10MG 4 PAEstrogensALORA PTTW 0.025MG/24HR 4 QL (8 EA per 30 days)ALORA PTTW 0.05MG/24HR 4 QL (8 EA per 28 days)ALORA PTTW 0.075MG/24HR 4 QL (8 EA per 28 days)ALORA PTTW 0.1MG/24HR 4 QL (8 EA per 28 days)CENESTIN TABS 0.3MG 4 PACENESTIN TABS 0.45MG 4 PACENESTIN TABS 0.625MG 4 PACENESTIN TABS 0.9MG 4 PACENESTIN TABS 1.25MG 4 PADEPO-ESTRADIOL INJ 5MG/ML 4DIVIGEL GEL 1MG/GM 4ELESTRIN GEL 0.06% 4ENJUVIA TABS 0.3MG 4 QL (30 EA per 30 days)ENJUVIA TABS 0.45MG 4 QL (30 EA per 30 days)ENJUVIA TABS 0.625MG 4 QL (30 EA per 30 days)ENJUVIA TABS 0.9MG 4 QL (30 EA per 30 days)ENJUVIA TABS 1.25MG 4 QL (60 EA per 30 days)ESTRACE CREA 0.1MG/GM 4estradiol valerate inj 10mg/ml 2 MO GCestradiol valerate inj 20mg/ml 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 77