Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsamethyst tabs 20mcg; 90mcg 2 MO GCapri tabs 0.15mg; 30mcg 1 MO GCaranelle tabs 0; 0 2 MO GCaviane tabs 20mcg; 0.1mg 1 MO GCbalziva tabs 35mcg; 0.4mg 2 MO GCbriellyn tabs 35mcg; 0.4mg 2 MO GCCLIMARA PRO PTWK 0.045MG/DAY; 0.015MG/DAY 4 QL (4 EA per 28 days)COMBIPATCH PTTW 0.05MG/DAY; 0.14MG/DAY 4 QL (8 EA per 28 days)COMBIPATCH PTTW 0.05MG/DAY; 0.25MG/DAY 4 QL (8 EA per 28 days)cryselle-28 tabs 30mcg; 0.3mg 1 MO GCcyclafem 1/35 tabs 35mcg; 1mg 1 MO GCcyclafem 7/7/7 tabs 0; 0 1 MO GCemoquette tabs 0.15mg; 30mcg 2 MO GCenpresse-28 tabs 0; 0 1 MO GCestradiol/norethindrone acetate tabs 1mg; 0.5mg 2 MO GCFEMHRT LOW DOSE TABS 2.5MCG; 0.5MG 4gianvi tabs 3mg; 0.02mg 1 MO GCintrovale tabs 0.03mg; 0.15mg 2 MO GCjinteli tabs 5mcg; 1mg 1 MO GCjunel 1.5/30 tabs 30mcg; 1.5mg 1 MO GCjunel 1/20 tabs 20mcg; 1mg 1 MO GCjunel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 2 MO GCjunel fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO GCkariva tabs 0; 0 2 MO GCkelnor 1/35 tabs 35mcg; 1mg 2 MO GCleena tabs 0; 0 2 MO GClessina tabs 20mcg; 0.1mg 2 MO GClevora 0.15/30-28 tabs 30mcg; 0.15mg 2 MO GClow-ogestrel tabs 30mcg; 0.3mg 1 MO GClutera tabs 20mcg; 0.1mg 1 MO GCmarlissa tabs 0.03mg; 0.15mg 1 QL (28 EA per 28 days) MO GCmicrogestin 1.5/30 tabs 30mcg; 1.5mg 1 MO GCmicrogestin 1/20 tabs 20mcg; 1mg 1 MO GCmicrogestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 2 MO GCmicrogestin fe tabs 20mcg; 75mg; 1mg 1 MO GCmononessa tabs 35mcg; 0.25mg 1 MO GCnecon 0.5/35-28 tabs 35mcg; 0.5mg 2 MO GCnecon 1/35 tabs 35mcg; 1mg 1 MO GCnecon 7/7/7 tabs 0; 0 1 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 79