Prescription Drug Guide Comprehensive list of covered drugs

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Drug NameDrugTier Requirements/Limitslevoxyl tabs 100mcg 1 MO GClevoxyl tabs 112mcg 1 MO GClevoxyl tabs 125mcg 1 MO GClevoxyl tabs 137mcg 1 MO GClevoxyl tabs 150mcg 1 MO GClevoxyl tabs 175mcg 1 MO GClevoxyl tabs 200mcg 1 MO GClevoxyl tabs 25mcg 1 MO GClevoxyl tabs 50mcg 1 MO GClevoxyl tabs 75mcg 1 MO GClevoxyl tabs 88mcg 1 MO GCliothyronine sodium tabs 25mcg 1 MO GCliothyronine sodium tabs 50mcg 1 MO GCliothyronine sodium tabs 5mcg 1 MO GCSYNTHROID TABS 100MCG 3 MOSYNTHROID TABS 112MCG 3 MOSYNTHROID TABS 125MCG 3 MOSYNTHROID TABS 137MCG 3 MOSYNTHROID TABS 150MCG 3 MOSYNTHROID TABS 175MCG 3 MOSYNTHROID TABS 200MCG 3 MOSYNTHROID TABS 25MCG 3 MOSYNTHROID TABS 300MCG 3 MOSYNTHROID TABS 50MCG 3 MOSYNTHROID TABS 75MCG 3 MOSYNTHROID TABS 88MCG 3 MOTIROSINT CAPS 100MCG 4TIROSINT CAPS 112MCG 4TIROSINT CAPS 125MCG 4TIROSINT CAPS 137MCG 4TIROSINT CAPS 25MCG 4TIROSINT CAPS 50MCG 4TIROSINT CAPS 75MCG 4TIROSINT CAPS 88MCG 4unithroid tabs 100mcg 1 MO GCunithroid tabs 112mcg 1 MO GCunithroid tabs 125mcg 1 MO GCunithroid tabs 150mcg 1 MO GCPA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemoscobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia deCobertura para obtener más información sobre esta cobertura. GC D = Cobertura adicional durante la brecha para ciertoplanes. LA=Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información,consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios conTTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por correo. ED=Estemedicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. Lacantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total demedicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe).Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayudaadicional para pagar este medicamento. Page 82
Drug NameDrugTier Requirements/Limitsunithroid tabs 175mcg 1 MO GCunithroid tabs 200mcg 1 MO GCunithroid tabs 25mcg 1 MO GCunithroid tabs 300mcg 1 MO GCunithroid tabs 50mcg 1 MO GCunithroid tabs 75mcg 1 MO GCunithroid tabs 88mcg 1 MO GCHormonal Agents, Stimulant/Replacement/Modifying(Adrenal)Glucocorticoids/Mineralocorticoidsdesoximetasone oint 0.05% 2hydrocortisone butyrate crea 0.1% 2hydrocortisone butyrate oint 0.1% 2hydrocortisone butyrate soln 0.1% 2methylprednisolone sodiumsuccinate inj 125mg 1methylprednisolone sodiumsuccinate inj 40mg 1procto-pak crea 1% 1 MOproctozone-hc crea 2.5% 1 MOHormonal Agents, Stimulant/Replacement/Modifying(Pituitary)Hormonal Agents, Stimulant/Replacement/Modifying(Pituitary)ACTHAR HP INJ 80UNIT/ML 5 PAnovarel inj 10000unit 2 PAHormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)AndrogensANDRODERM PT24 2MG/24HR 3 PA MOANDRODERM PT24 4MG/24HR 3 PA MOHormonal Agents, Suppressant (Adrenal)Hormonal Agents, Suppressant (Adrenal)LYSODREN TABS 500MG 3 MOHormonal Agents, Suppressant (Parathyroid)Hormonal Agents, Suppressant (Parathyroid)SENSIPAR TABS 30MG 3 PA MOSENSIPAR TABS 60MG 3 PA MOSENSIPAR TABS 90MG 3 PA MOHormonal Agents, Suppressant (Pituitary)Hormonal Agents, Suppressant (Pituitary)PA = 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 83
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Prescription Drug GuideGuía de Med
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What is the Simply Healthcare Plans
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have two options:You can ask Member
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The information in the Requirements
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Simply Healthcare Plans, Inc.Formul
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¿Cómo uso el formulario?Hay dos m
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estricciones de uso adicional no so
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Cobertura para obtener más informa
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Drug NameDrugTier Requirements/Limi
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Page 97: Drug NameDrugTier Requirements/Limi
Page 121 and 122: IndexAabacavir ....................
Page 123 and 124: chloroquine phosphate..............
Page 125 and 126: faslodex ..........................
Page 127 and 128: linzess............................
Page 129 and 130: peganone...........................
Page 131 and 132: testosterone cypionate ............
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Prescription Drug Guide Comprehensive list of covered drugs

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