Prescription Drug Guide Comprehensive list of covered drugs

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