Prescription Drug Guide Comprehensive list of covered drugs

Drug NameDrugTier Requirements/Limitsmedroxyprogesterone acetate tabs 5mg 1 MO GCmegestrol acetate susp 40mg/ml 1 MO GCmegestrol acetate tabs 20mg 1 MO GCmegestrol acetate tabs 40mg 1 MO GCnext choice tabs 0.75mg 2 MO GCnora-be tabs 0.35mg 1 MO GCnorethindrone acetate tabs 5mg 2 MO GCprogesterone caps 100mg 2 MO GCprogesterone caps 200mg 2 MO GCSelective Estrogen Receptor Modifying AgentsEVISTA TABS 60MG 3 QL (30 EA per 30 days) MOHormonal Agents, Stimulant/ Replacement/ Modifying(Thyroid)Hormonal Agents, Stimulant/ Replacement/ Modifying(Thyroid)levothroid tabs 100mcg 1 MO GClevothroid tabs 112mcg 1 MO GClevothroid tabs 125mcg 1 MO GClevothroid tabs 137mcg 1 MO GClevothroid tabs 150mcg 1 MO GClevothroid tabs 175mcg 1 MO GClevothroid tabs 200mcg 1 MO GClevothroid tabs 25mcg 1 MO GClevothroid tabs 300mcg 1 MO GClevothroid tabs 50mcg 1 MO GClevothroid tabs 75mcg 1 MO GClevothroid tabs 88mcg 1 MO GClevothyroxine sodium tabs 100mcg 1 MO GClevothyroxine sodium tabs 112mcg 1 MO GClevothyroxine sodium tabs 125mcg 1 MO GClevothyroxine sodium tabs 137mcg 1 MO GClevothyroxine sodium tabs 150mcg 1 MO GClevothyroxine sodium tabs 175mcg 1 MO GClevothyroxine sodium tabs 200mcg 1 MO GClevothyroxine sodium tabs 25mcg 1 MO GClevothyroxine sodium tabs 300mcg 1 MO GClevothyroxine sodium tabs 50mcg 1 MO GClevothyroxine sodium tabs 75mcg 1 MO GClevothyroxine sodium tabs 88mcg 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 81