Prescription Drug Guide Comprehensive list of covered drugs

Prescription Drug Guide
Guía de Medicamentos Recetados
Comprehensive list of
covered drugs
Lista de medicamentos cubiertos
2013
South Florida & Tampa Region
Sur de la Florida y Región de Tampa
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN.
FAVOR LEER: ESTE DOCUMENTO CONTIENE INFORMACION
SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN.
H5471_SHP 2013CFORM_BIL
Simply Healthcare Plans, Inc.
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,
2014.
Simply HealthCare Plans, Inc. is a Coordinated Care plan with a Medicare contract and a contract with
the Florida Medicaid program.
This information is available for free in other languages. Please contact our Member Services number at
1-877-577-0115 for additional information. If you use a TTY device, please call 711. We are open 7
days a week, 8 a.m. to 8 p.m. From February 15th until September 30th, you may leave us a voice mail
message after hours, Saturdays, Sundays and holidays, and we will return your call the next business
day.
Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestro
número de atención al afiliado al 1-877-577-0115 para obtener información adicional. Si usted usa un
dispositivo TTY, por favor llame al 711. El horario de atención es de 8 a.m. a 8 p.m., los siete días de la
semana. A partir del 15 de febrero hasta el 30 de septiembre usted puede dejarnos un mensaje en el
correo de voz después del horario de trabajo, los sábados, domingos y días festivos y nosotros le
devolveremos la llamada el siguiente día hábil.
Formulary ID: 13569 Ver. 13
H5471_SHP 2013CForm_BIL
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What is the Simply Healthcare Plans, Inc.’s Formulary?
A formulary is a list of covered drugs selected by Simply Healthcare Plans, Inc. in consultation with a
team of health care providers, which represents the prescription therapies believed to be a necessary part
of a quality treatment program. Simply Healthcare Plans, Inc. will generally cover the drugs listed in
our formulary as long as the drug is medically necessary, the prescription is filled at a Simply Healthcare
Plans, Inc. network pharmacy, and other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug. It will remain available at the
same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is
important that you have continued access for the remainder of the coverage year to the formulary drugs
that were available when you chose our plan, except for cases in which you can save additional money
or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of September 1, 2012. To get
updated information about the drugs covered by Simply Healthcare Plans, Inc., please visit our Web site
at www.mysimplymedicare.com or call Member Services at 1-877-577-0115. We are open 7 days a
week, 8 a.m to 8 p.m. From February 15 until the following Annual Election Period (AEP), you may
leave us a voice mail message after-hours, Saturdays, Sundays and holidays and we will return your call
the next business day. TTY/TDD users should call 711. In the event of a mid-year non-maintenance
formulary change such as changing a preferred or non-preferred formulary drug, adding an additional
requirement or limit to a drug, remove a dosage form, or exchanging therapeutic alternatives by adding
or deleting a drug or changing a tier as a result of a therapeutic alternative, we will notify you by
providing you with a written notice of the non-maintenance formulary change.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is
used for, look for the category name in the list that begins on page number 1. Then look under the
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category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 53. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first column
of the list.
What are generic drugs?
Simply Healthcare Plans, Inc. covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic
drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
x
Prior Authorization: Simply Healthcare Plans, Inc. requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Simply
Healthcare Plans, Inc. before you fill your prescriptions. If you don’t get approval, Simply
Healthcare Plans, Inc. may not cover the drug.
x
Quantity Limits: For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drug
that Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.
provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to a
standard one month or three month supply.
x
Step Therapy: In some cases, Simply Healthcare Plans, Inc. requires you to first try certain
drugs to treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc.
may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Simply
Healthcare Plans, Inc. will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site at www.mysimplymedicare.com.
You can ask Simply Healthcare Plans, Inc. to make an exception to these restrictions or limits. See the
section, “How do I request an exception to the Simply Healthcare Plans, Inc.’s formulary?” on page iv
for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm that
your drug is not covered. If you learn that Simply Healthcare Plans, Inc. does not cover your drug, you
iii
have two options:
x
You can ask Member Services for a list of similar drugs that are covered by Simply Healthcare
Plans, Inc. When you receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by Simply Healthcare Plans, Inc.
x
You can ask Simply Healthcare Plans, Inc. to make an exception and cover your drug. See below
for information about how to request an exception.
How do I request an exception to the Simply Healthcare Plans, Inc.’s Formulary?
You can ask Simply Healthcare Plans, Inc. to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.
x
You can ask us to cover your drug even if it is not on our formulary.
x
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, Simply Healthcare Plans, Inc. limits the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive the limit and cover more.
x
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in
our non-preferred brand tier, you can ask us to cover it at the cost-sharing amount that applies to
drugs in the preferred brand tier instead. This would lower the amount you must pay for your
drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may
not ask us to provide a higher level of coverage for the drug. “Also, you may not ask us to
provide a higher level of coverage for drugs that are in the Tier 5, Specialty tier.”
Generally, Simply Healthcare Plans, Inc. will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your physician supporting your request. Generally,
we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s
supporting statement. You can request an expedited (fast) exception if you or your doctor believe that
your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or
prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the right
iv
course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to
a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we
have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
For current members who are changing from one treatment setting to another, for example entering a
long- term care facility from a hospital or being discharged from a hospital to home, the member and
provider will need to utilize our exception and appeals process should the drugs not be on our formulary.
Members entering or being discharged from a long-term care facility will be allowed a one-time
emergency supply of a 31-day supply for medications which the member has not already received a
transition supply. In addition, the dispensing pharmacist will need to call the Pharmacy Help Desk to
receive appropriate directions to dispense a prescription required due to a level of care change.
For more information
For more detailed information about your Simply Healthcare Plans, Inc. prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
If you have questions about Simply Healthcare Plans, Inc., please call Member Services at 1-877-5770115. If you use a TTY device, please call 711. We are open 7 days a week, 8 a.m. to 8 p.m. From
February 15th until September 30th, you may leave us a voice mail message after hours, Saturdays,
Sundays and holidays, and we will return your call the next business day. Or visit
www.mysimplymedicare.com.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-4862048. Or visit www.medicare.gov.
Simply Healthcare Plans, Inc.’s Formulary
The formulary below provides coverage information about some of the drugs covered by Simply
Healthcare
Plans, Inc. If you have trouble finding your drug in the list, turn to the Index that begins on page 53.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR 10
MG) and generic drugs are listed in lower-case italics (e.g., pravastatin sodium 10 mg).
v
The information in the Requirements/Limits column tells you if Simply Healthcare Plans, Inc. has any
special requirements for coverage of your drug.
List of Abbreviations
B/D
This prescription drug has a Part B versus D administrative prior authorization requirement. This
drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may need to be submitted describing the use and setting of the drug to make the
determination.
ED
This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The
amount you pay when you fill a prescription for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In
addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra
help to pay for this drug.
GC
Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.
Please refer to our Evidence of Coverage for more information about this coverage.
GCD
Additional Gap Coverage for specific plans. We provide additional coverage of this prescription
drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage.
LA
Limited Availability. This prescription may be available only at certain pharmacies. For more
information consult your Provider/Pharmacy Directory or call Member Services at 1-877-5770115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.
MO
Mail Order Drug. This prescription drug is available through a mail-order service.
PA
Prior Authorization. Simply Healthcare Plans, Inc. requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Simply
Healthcare Plans, Inc. before you fill your prescriptions. If you don't get approval, Simply
Healthcare Plans, Inc. may not cover the drug.
QL
Quantity Limit. For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drug
that Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.
provides 30 tablets per prescription for Celebrex 100mg Capsules. This may be in addition to a
standard one month or three month supply.
ST
Step Therapy. In some cases, Simply Healthcare Plans, Inc requires you to first try certain drugs
to treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc
may not cover drug B unless you try Drug A first. If Drug A does not work for you, Simply
Healthcare Plans, Inc will then cover Drug.
vi
Formulary
Drug Tier
Formulary Drug
Label Name
Copayment/Co-insurance
at Retail and Mail Order
Pharmacies
1
Preferred Generic
Lowest Copayment
2
Non-Preferred Generic
Low Copayment
3
Preferred Brand
Medium Copayment
4
Non-Preferred Brand
High Copayment
Explanation
Copayment for a 30-day
supply retail or 90-day
supply mail-order/ per
prescription or refill.
Copayment for a 30-day
supply retail or 90-day
supply mail-order/ per
prescription or refill.
Copayment for a 30-day
supply retail or 90-day
supply mail-order/ per
prescription or refill.
Copayment for a 30-day
supply retail/ per
prescription or refill.
Coinsurance for a 30-day
supply retail/ per
prescription or refill.
Note: Please see your Evidence of Coverage for specific cost sharing amounts and for the
availability of 90-Day Retail & Mail-Order supplies for Tier 1-3. Members getting Extra Help will
pay their Low Income Subsidy (LIS) copayment. Please refer to your LIS rider or call Member
Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. If you use a TTY device,
please call 711.
5
Specialty Tier
High Co-Insurance
vii
Simply Healthcare Plans, Inc.
Formulario de 2013
(Lista de medicamentos cubiertos)
LEA POR FAVOR: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRE ESTE PLAN
Nota a los afiliados existentes: Este formulario ha cambiado desde el año pasado. Revise este
documento para asegurarse de que sigue incluyendo los medicamentos que toma.
Los beneficiarios deben usar las farmacias de la red para tener acceso a su beneficio de medicamentos
recetados. El 1 de enero de 2014 podría haber cambios en los beneficios, el formulario, la red de
farmacias, las primas, los copagos o el coaseguro.
Simply HealthCare Plans, Inc. es un Plan de cuidados coordinados con un contrato Medicare Advantage
y un contrato con el programa de Medicaid de la Florida.
This information is available for free in other languages. Please contact our member service number at
1-877-577-0115 for additional information. If you use a TTY device, please call 711. We are open 7
days a week, 8 a.m. to 8 p.m. From February 15 th until September 30th, you may leave us a voice mail
message after hours, Saturdays, Sundays and holidays, and we will return your call the next business
day.
Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestro
número de atención al afiliado al 1-877-577-0115 para obtener información adicional. Si usted usa un
dispositivo TTY, por favor llame al 711. El horario de atención es de 8 a.m. a 8 p.m., los siete días de la
semana. A partir del 15 de febrero hasta el 30 de septiembre usted puede dejarnos un mensaje en el
correo de voz después del horario de trabajo, los sábados, domingos y días festivos y nosotros le
devolveremos la llamada el siguiente día hábil.
viii
¿Qué es el Formulario de Simply Healthcare Plans, Inc.?
El formulario es una lista de medicamentos seleccionados cubiertos por Simply Healthcare Plans, Inc. en
colaboración con un equipo de proveedores de atención médica, que representa las terapias
farmacológicas consideradas como parte necesaria de un programa de tratamiento de calidad. Por lo
general, Simply Healthcare Plans, Inc. cubrirá los medicamentos incluidos en nuestro formulario
siempre y cuando se necesiten por razones médicas, el medicamento sea surtido en una farmacia de la
red de Simply Healthcare Plans, Inc., y se hayan seguido otras reglas de cobertura. Si desea más
información sobre cómo hacer para que le surtan sus medicamentos recetados, consulte su Evidencia de
Cobertura.
¿Es posible que cambie el formulario?
Por lo general, si está tomando un medicamento de nuestro formulario del 2013 que estaba cubierto al
principio del año, no lo descontinuaremos ni reduciremos su cobertura durante el año de cobertura 2013,
excepto cuando un medicamento genérico nuevo y menos costoso se ponga a disposición, o cuando se
publique nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de
cambios en el formulario, como el retiro de un medicamento de nuestro formulario, no afectará a los
afiliados que están tomando actualmente el medicamento. Seguirá estando disponible con la misma
participación de costos para aquellos afiliados que lo están tomando durante el resto del año de
cobertura. Creemos que es importante que usted tenga acceso continuo durante el resto del año de la
cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan,
excepto en los casos en los que pueda ahorrar dinero o podamos garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario o añadimos autorizaciones previas, límites en las
cantidades o restricciones en la terapia por fases en un medicamento, o trasladamos un medicamento a
un nivel con distribución de costos más alta, debemos notificar a los afiliados afectados sobre el cambio
cuando menos con 60 días de anticipación a que entre en vigencia. Alternativamente, daremos
notificación cuando el afiliado solicite la repetición de la receta del medicamento, momento en el cual el
afiliado recibirá un surtido de 60 días del medicamento en cuestión. Si la Administración de Alimentos
y Medicamentos considera que un medicamento en nuestro formulario no es seguro, o el fabricante del
medicamento lo retira del mercado, nosotros eliminaremos inmediatamente dicho medicamento de
nuestro formulario y daremos aviso a los afiliados que lo usan. El formulario adjunto fue actualizado el
1 de Septiembre del 2012. Si desea información actualizada de los medicamentos cubiertos por Simply
Healthcare Plans, Inc., visite nuestro sitio web en www.mysimplymedicare.com o comuníquese con el
Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Estamos disponibles los 7 días
de la semana de 8 a.m. a 8 p.m. a partir del 15 de Febrero hasta el próximo periodo Anual de Elecciones
(AEP por sus siglas en Ingles) puede dejarnos un mensaje de voz después del horario de trabajo, los
sábados, domingos y días festivos y le devolveremos la llamada al siguiente día hábil. Los usuarios con
TTY/TDD deben marcar 711. En caso de que se haga un cambio en el formulario de un medicamento
que no sea de mantenimiento a mitad de año, como el cambio de un medicamento preferido o no
preferido del formulario, añadir un requisito adicional o poner un límite a un medicamento, retirar una
forma de dosis, o intercambiar alternativas terapéuticas agregando o eliminando un medicamento o
cambiando un nivel como resultado de una alternativa terapéutica, se lo notificaremos mediante aviso
por escrito del cambio en el formulario del medicamento que no es de mantenimiento.
ix
¿Cómo uso el formulario?
Hay dos maneras de encontrar su medicamento en el formulario.
Afección
El formulario comienza en la página 1. Los medicamentos en este formulario se agrupan en
categorías en función del tipo de afecciones que tratan habitualmente. Por ejemplo, los
medicamentos para tratar afecciones cardiacas se incluyen en la categoría “Agentes
Cardiovasculares”. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la
lista que comienza en la página 1. A continuación busque su medicamento en dicha categoría.
Lista en orden alfabético
Si no sabe a qué categoría corresponde su medicamento, deberá buscarlo en el Índice que comienza
en la página 53. El Índice ofrece una lista alfabética de todos los medicamentos incluidos en este
documento. El Índice incluye tanto los medicamentos de marca como los genéricos. Busque en el
Índice para encontrar su medicamento. Junto al medicamento, verá el número de la página que
contiene la información sobre la cobertura. Vaya a la página indicada en el Índice y encuentre el
nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Simply Healthcare Plans, Inc. cubre medicamentos genéricos y de marca. Un medicamento genérico
recibirá la aprobación de la FDA si tiene el mismo ingrediente activo que el medicamento de marca. Por
lo general, los medicamentos genéricos cuestan menos que los de marca.
¿Hay restricciones en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura.
Estos requisitos y límites pueden incluir:
x
Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtengan
autorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobación
de Simply Healthcare Plans, Inc. antes de que pueda surtir sus recetas. Si no obtiene la
aprobación, es posible que Simply Healthcare Plans, Inc. no cubra el medicamento.
x
Límites en la Cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. limita la
cantidad del medicamento que Simply Healthcare Plans, Inc. va a cubrir. Por ejemplo, Simply
Healthcare Plans, Inc. proporciona 30 tabletas por receta del medicamento LIPITOR EN
TABLETAS DE 10 MG. Esto puede ser adicional al suministro estándar de un mes o tres
meses.
x
Terapia por Fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebe
primero ciertos medicamentos para tratar su condición médica antes de que demos cobertura a
otro medicamento para dicha afección. Por ejemplo, si tanto el Medicamento A como el
Medicamento B tratan su condición médica, es posible que Simply Healthcare Plans, Inc. no
cubra el Medicamento B a menos que usted pruebe primero el Medicamento A. Si el
Medicamento A no funciona en su caso, Simply Healthcare Plans, Inc. cubrirá el Medicamento
B.
x
Usted puede consultar el formulario que comienza en la página 1 para determinar si su medicamento
tiene requisitos o límites adicionales. También puede obtener más información sobre las restricciones
que se aplican a medicamentos cubiertos específicos si visita nuestro sitio web en
www.mysimplymedicare.com.
Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o límites.
Consulte la sección “¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?”
en la pagina xi obtener información sobre cómo solicitar una excepción.
¿Qué sucede si su medicamento no está en el formulario?
Si su medicamento no está incluido en esta lista, debe comunicarse primero con el Departamento de
Servicios para Afiliados para confirmar que no está cubierto. Si se entera de que Simply Healthcare
Plans, Inc. no cubre su medicamento, usted tiene dos opciones:
x
Puede comunicarse con el Departamento de Servicios para Afiliados para solicitar una lista de
los medicamentos similares que cubre Simply Healthcare Plans, Inc. Cuando la reciba,
muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por
Simply Healthcare Plans, Inc.
x
Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o
límites. Consulte la sección que sigue para obtener información sobre cómo solicitar una
excepción.
¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?
Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a nuestras reglas de cobertura.
Hay varios tipos de excepciones que puede pedir.
x
Puede solicitarnos que cubramos su medicamento aunque no esté incluido en nuestro
formulario.
x
Puede solicitarnos que cancelemos las restricciones o limitaciones en la cobertura para su
medicamento. Por ejemplo, en algunos medicamentos, Simply Healthcare Plans, Inc. limita la
cantidad que tendrá cobertura. Si su medicamento tiene un límite en la cantidad, puede
solicitarnos que cancelemos dicha limitación y cubramos una mayor cantidad.
x
Puede pedirnos que proporcionemos un nivel de cobertura más alto para su medicamento. Si su
medicamento está incluido en nuestro nivel de medicamentos de marca no preferidos, puede
solicitarnos que en su lugar lo cubramos en el nivel de participación de costos que se aplica a los
medicamentos que están en el nivel de medicamentos de marca preferidos. Esto reduciría la
cantidad que debe pagar por el medicamento. Tenga presente que si concedemos la solicitud de
cubrir un medicamento que no se incluye en nuestro formulario, usted no puede pedirnos que
demos un nivel de cobertura más alto para dicho medicamento. “Asimismo, no puede pedirnos
que demos un nivel de cobertura más alto a los medicamentos que están en el Nivel 5, que
corresponde a los medicamentos especiales.”
Por lo general, Simply Healthcare Plans, Inc. solo aprobará su solicitud para una excepción si los
medicamentos alternativos incluidos en el formulario del plan, o el medicamento de nivel más bajo o las
xi
restricciones de uso adicional no son tan eficaces para tratar su afección o pueden ocasionar efectos
médicos adversos.
Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción en el
formulario, el nivel o la limitación en el uso. Cuando solicite una excepción en el formulario, el nivel
o la limitación en el uso, debe presentar una declaración de su médico que respalde su solicitud.
Por lo general, debemos tomar una decisión en un plazo de 72 horas a partir del momento en el que
hayamos recibido la declaración de respaldo de su médico tratante o de quien le receta. Usted puede
solicitar una excepción acelerada (rápida) si su médico considera que una espera de 72 horas para una
decisión puede perjudicar gravemente su salud. Si se concede acelerar su solicitud, debemos otorgarle
una decisión antes de 24 horas a partir del momento en que recibamos la declaración de respaldo de su
médico tratante o de quien le receta.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de mis
medicamentos o la solicitud de una excepción?
Si usted es afiliado nuevo o continúa en nuestro plan, podría estar tomando medicamentos que no están
en nuestro formulario. O podría estar tomando un medicamento que está en nuestro formulario pero su
capacidad para adquirirlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra
parte para poder surtir su receta. Debe hablar con su médico para decidir si debe cambiar a un
medicamento apropiado que nosotros cubramos o solicitar una excepción en el formulario para que
podamos cubrir el medicamento que está tomando. Mientras habla con su médico para determinar el
mejor modo de actuar para usted, podríamos cubrir su medicamento en ciertos casos durante los
primeros 90 días de su afiliación a nuestro plan.
Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para adquirir
sus medicamentos es limitada, daremos cobertura a un suministro temporal de 30 días (a menos que
tenga una receta para un número menor de días) cuando vaya a una farmacia de la red. Después de su
primer suministro de 30 días, nosotros no pagaremos estos medicamentos, incluso si usted ha estado
afiliado al plan menos de 90 días.
Si reside en un establecimiento de atención médica prolongada, le permitiremos que surta su receta hasta
que hayamos proporcionado un suministro de transición de 93 días, consistente con el incremento en el
suministro, (a menos que su receta indique un número menor de días). Daremos cobertura a más de un
surtido de estos medicamentos durante los primeros 90 días de su afiliación a nuestro plan. Si necesita
un medicamento que no está en nuestro formulario, o si su capacidad para adquirir sus medicamentos es
limitada, pero han pasado los primeros 90 días de su afiliación a nuestro plan, daremos cobertura a un
suministro de emergencia de 31 días de dicho medicamento (a menos que su receta indique un número
menor de días) mientras busca una excepción en el formulario.
Para los afiliados actuales que están cambiando de un lugar de tratamiento a otro, por ejemplo, si
después de estar en un hospital ingresan a un establecimiento de atención médica prolongada, o que
regresan a su hogar después de ser dados de alta de un hospital, el afiliado y el proveedor deberán
utilizar nuestro proceso de excepciones y apelaciones en caso de que los medicamentos no estén en
nuestro formulario. Los afiliados que ingresan a un establecimiento de atención médica prolongada, o
que salen de él, tendrán permitido un suministro único de emergencia de 31 días de los medicamentos
para los cuales no hayan recibido aún un suministro de transición. Adicionalmente, el farmacéutico que
surte la receta deberá comunicarse con el Centro de Ayuda para Farmacias con el fin de recibir
instrucciones apropiadas para surtir una receta requerida debido a un cambio en el nivel de la atención.
xii
Si desea más información
Si desea información detallada sobre su cobertura de medicamentos recetados de Simply Healthcare
Plans, Inc., consulte su Evidencia de Cobertura y demás documentos del plan.
Si tiene preguntas sobre Simply Healthcare Plans, Inc., comuníquese con el Departamento de Servicios
para Afiliados llamando al 1-877-577-0115. Los usuarios con TTY/TDD deben marcar 711. Estamos
disponibles los 7 días de la semana de 8 a.m. a 8 p.m. a partir del 15 de Febrero hasta el 30 de
septiembre puede dejarnos un mensaje de voz después del horario de trabajo, los sábados, domingos y
días festivos y devolveremos la llamada al siguiente día hábil. O visite www.mysimplymedicare.com.
Si tiene alguna pregunta general sobre la cobertura de medicamentos recetados de Medicare,
comuníquese con Medicare llamando al 1-800-MEDICARE (1-800-633-4227). Se atiende las 24 horas
del día, los 7 días de la semana. Las personas con impedimentos auditivos pueden llamar al 1-877-4862048 o visitar la página www.medicare.gov.
Formulario de Simply Healthcare Plans, Inc.
El formulario que se ofrece a continuación proporciona información de cobertura de algunos de los
medicamentos cubiertos por Simply Healthcare Plans, Inc. Si tiene problemas para encontrar su
medicamento en la lista, diríjase al Índice que comienza en la página 53.
En la primera columna del diagrama se incluye el nombre del medicamento. Los medicamentos de
marca están con letras mayúsculas (por ejemplo, LIPITOR 10 MG), y los medicamentos genéricos se
incluyen con letras minúsculas en itálica (por ejemplo, pravastatin sodium 10 mg).
La información en la columna de requisitos y límites indica si Simply Healthcare Plans, Inc. tiene algún
requisito especial para dar cobertura a su medicamento.
Listado De Abreviaciones
B/D
Autorización Previa B v D. Dependiendo de las circunstancias, este medicamento podría tener
cobertura bajo la Parte B o la Parte D de Medicare. Puede ser necesario enviar información
sobre el uso del medicamento y la situación específica para tomar una determinación.
ED
Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos
Recetados de Medicare. La cantidad que usted paga cuando le surten una receta de este
medicamento no se toma en cuenta en su costo total de medicamentos (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 ayuda
adicional para pagar por este medicamento.
GC
Cobertura adicional. Proporcionamos cobertura adicional de este medicamento recetado durante
la brecha en la cobertura. Consulte nuestra Evidencia de Cobertura para obtener más
información sobre esta cobertura.
GCD
Cobertura adicional durante la brecha para ciertos planes. Proporcionamos cobertura adicional
de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
xiii
Cobertura para obtener más información sobre esta cobertura.
LA
Disposición Limitada. Este medicamento recetado solo podría estar disponible en algunas
farmacias. Si desea más información, consulte su Directorio de proveedores/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 con
TTY/TDD deben marcar 711.
MO
Este medicamento recetado puede obtenerse mediante pedido por correo.
PA
Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtenga
autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener la
aprobación de Simply Healthcare Plans, Inc. antes de adquirir su medicamento. Si no obtiene
aprobación, Simply Healthcare Plans, Inc. podría no cubrir el medicamento.
QL
Límites en la cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. establece
límites en las cantidades que cubre. Por ejemplo, Simply Healthcare Plans, Inc. proporciona 30
tabletas por receta del medicamento Celebrex en capsulas de 100mg. Esto puede ser adicional al
suministro estándar de un mes o tres meses.
ST
Terapia por fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebe
primero ciertos medicamentos para el tratamiento de su condición médica antes que cubramos
otros medicamentos indicados para ese tratamiento. Por ejemplo, si los medicamentos A y B
están indicados para el tratamiento de su condición médica, es posible que Simply Healthcare
Plans, Inc. no cubra el medicamento B si usted no prueba primero el medicamento A. Si el
medicamento A no es efectivo, entonces Simply Healthcare Plans, Inc. cubrirá el medicamento
B.
xiv
Nivel del
Medicamento
en el
Formulario
Nombre del Nivel en
el Formulario
Copago/Coaseguro en
Farmacias Minoristas y
Farmacias con Pedidos
por Correo
Explicación
Copago por un suministro
de 30 días por receta o
relleno en farmacias
1
Genérico Preferido
Copago mas bajo
minoristas o copago por un
suministro de 90 días por
receta o relleno para pedido
por correo.
Copago por un suministro
de 30 días por receta o
relleno en farmacias
2
Genérico No-Preferido
Copago bajo
minoristas o copago por un
suministro de 90 días por
receta o relleno para pedido
por correo.
Copago por un suministro
de 30 días por receta o
relleno en farmacias
Medicamento de Marca
3
Copago Mediano
minoristas o copago por un
Preferido
suministro de 90 días por
receta o relleno para pedido
por correo.
Copago por un suministro
Medicamento de Marca
de 30 días por receta o
Alto Copago
4
No- Preferido
relleno en farmacias
minoristas.
Coaseguro por un
Medicamentos
suministro de 30 días por
5
Alto Coaseguro
especiales
receta o relleno en
farmacias minoristas.
Nota: Por favor consulte nuestra Evidencia de Cobertura para obtener más información sobre sus
copagos y la disponibilidad de un suministro de 90 días en farmacias minoristas y pedidos por correo
de medicamentos en los Niveles 1-3. Afiliados recibiendo ayuda adicional pagaran el copago
establecido en la Clausula para el subsidio por ingreso limitado. Por favor refiérase a su Clausula
para el subsidio por ingreso limitado o llame a nuestro Departamento de Servicios para el afiliado 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 con TTY deben marcar 711.
xv
Drug Name
Analgesics
Analgesics
acetaminophen/caffeine/dihydrocodeine bitartrate
acetaminophen/codeine #3
acetaminophen/codeine soln
acetaminophen/codeine tabs 300mg, 60mg
acetaminophen/codeine tabs 300mg, 15mg
ARTHROTEC 50
ARTHROTEC 75
ascomp/codeine
butalbital/acetaminophen/caffeine/codeine
BUTRANS PTWK 5MCG/HR
BUTRANS PTWK 10MCG/HR, 20MCG/HR
carisoprodol/aspirin
carisoprodol/aspirin/codeine
co-gesic
endocet tabs 325mg, 5mg
endocet tabs 650mg, 10mg
endocet tabs 500mg, 7.5mg
endocet tabs 325mg, 10mg, 325mg, 7.5mg
endodan
hydrocodone bitartrate/acetaminophen soln
hydrocodone bitartrate/acetaminophen tabs 750mg, 10mg
hydrocodone bitartrate/acetaminophen tabs 300mg, 10mg
hydrocodone bitartrate/acetaminophen tabs 300mg, 5mg
hydrocodone/acetaminophen soln
hydrocodone/acetaminophen tabs 750mg, 7.5mg
hydrocodone/acetaminophen tabs 325mg, 10mg, 500mg,
10mg, 500mg, 7.5mg, 650mg, 10mg, 650mg, 7.5mg, 660mg,
10mg
hydrocodone/acetaminophen tabs 325mg, 7.5mg, 500mg,
2.5mg, 500mg, 5mg
hydrocodone/acetaminophen tabs 325mg, 5mg
hydrocodone/ibuprofen
orphenadrine/asa/caffeine
oxycodone/acetaminophen caps
oxycodone/acetaminophen tabs 325mg, 5mg
oxycodone/acetaminophen tabs 650mg, 10mg
oxycodone/acetaminophen tabs 500mg, 7.5mg
Drug
Tier Requirements/Limits
2
1
1
1
1
4
4
2
2
4
4
2
2
1
1
2
2
2
1
1
1
1
1
1
1
1
QL (165 EA per 30 days) MO GC
QL (360 EA per 30 days) MO GC
QL (3240 ML per 30 days) MO GC
QL (360 EA per 30 days) MO GC
QL (390 EA per 30 days) MO GC
1
QL (240 EA per 30 days) MO GC
1
1
2
1
1
2
2
QL (360 EA per 30 days) MO GC
MO GC
PA MO GC
QL (240 EA per 30 days) MO GC
QL (360 EA per 30 days) MO GC
QL (180 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
MO GC
QL (180 EA per 30 days) MO GC
QL (10 EA per 30 days)
QL (4 EA per 28 days)
PA MO GC
PA MO GC
QL (240 EA per 30 days) MO GC
QL (360 EA per 30 days) MO GC
QL (180 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (360 EA per 30 days) MO GC
MO GC
QL (5520 ML per 30 days) MO GC
QL (150 EA per 30 days) MO GC
QL (180 EA per 30 days) MO GC
QL (360 EA per 30 days) MO GC
QL (3600 ML per 30 days) MO GC
QL (150 EA per 30 days) MO GC
QL (180 EA per 30 days) MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 1 of 73
Drug Name
oxycodone/acetaminophen tabs 325mg, 10mg, 325mg, 2.5mg,
325mg, 7.5mg
oxycodone/aspirin
pentazocine/acetaminophen
pentazocine/naloxone hcl
reprexain
ROXICET
stagesic
SYNALGOS-DC
tramadol hydrochloride/acetaminophen
Nonsteroidal Anti-inflammatory Drugs
CELEBREX CAPS 100MG
CELEBREX CAPS 200MG, 400MG, 50MG
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium/misoprostol
diflunisal
etodolac er
etodolac caps 200mg
etodolac tabs
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen susp
ibuprofen tabs 400mg, 600mg, 800mg
INDOCIN SUSP
indomethacin er
indomethacin caps
ketoprofen
ketoprofen er
ketorolac tromethamine tabs
ketorolac tromethamine inj 15mg/ml, 30mg/ml
MECLOFENAMATE SODIUM CAPS 50MG
meclofenamate sodium caps 100mg
mefenamic acid
meloxicam tabs
Drug
Tier Requirements/Limits
2 QL (360 EA per 30 days) MO GC
1
1
1
1
3
1
4
1
4
4
1
1
1
2
1
2
1
1
1
4
1
1
1
4
1
1
1
2
1
1
4
2
2
1
MO GC
QL (180 EA per 30 days) PA MO
GC
MO GC
MO GC
QL (1800 ML per 30 days) MO
QL (240 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
QL (20 EA per 30 days) PA MO GC
QL (20 ML per 30 days) PA MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 2 of 73
Drug Name
meloxicam susp
nabumetone
naproxen
naproxen dr
naproxen sodium tabs 275mg, 550mg
oxaprozin
oxycodone/ibuprofen
PENNSAID
piroxicam
sulindac
tolmetin sodium
Opioid Analgesics, Long-acting
ABSTRAL SUBL 100MCG
ABSTRAL SUBL 200MCG, 800MCG
astramorph
EXALGO TB24 12MG, 8MG
EXALGO TB24 16MG
FENTANYL CITRATE ORAL TRANSMUCOSAL
fentanyl pt72 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr
fentanyl pt72 100mcg/hr
FENTORA
methadone hcl tabs
methadone hcl soln 5mg/5ml
morphine sulfate er tb12
morphine sulfate er cp24
morphine sulfate soln, tabs
MS CONTIN TB12 100MG, 15MG, 30MG, 60MG
NUCYNTA ER TB12 50MG
NUCYNTA ER TB12 100MG, 150MG, 200MG, 250MG
ONSOLIS FILM 200MCG
ONSOLIS FILM 400MCG
OPANA ER (CRUSH RESISTANT) TB12 10MG, 20MG,
30MG, 5MG
OPANA ER (CRUSH RESISTANT) TB12 40MG
OXYCONTIN TB12 10MG, 15MG, 20MG, 30MG, 40MG,
60MG
OXYCONTIN TB12 80MG
oxymorphone hydrochloride er tb12 15mg
tramadol hcl er tb24
Drug
Tier
2
1
1
1
1
1
2
4
1
1
2
Requirements/Limits
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
4
5
1
4
5
5
2
2
5
1
1
1
2
1
4
4
4
5
5
3
QL (120 EA per 30 days) ST PA
QL (120 EA per 30 days) ST PA
MO GC
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days) PA
QL (15 EA per 30 days) MO GC
QL (30 EA per 30 days) MO GC
QL (120 EA per 30 days) ST PA
MO GC
MO GC
QL (60 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
MO GC
QL (60 EA per 30 days)
QL (300 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days) ST PA
QL (90 EA per 30 days) ST PA
QL (60 EA per 30 days) MO
5
4
QL (60 EA per 30 days)
QL (60 EA per 30 days)
5
2
2
QL (120 EA per 30 days)
QL (60 EA per 30 days) MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 3 of 73
Drug Name
Opioid Analgesics, Short-acting
butorphanol tartrate nasal soln
butorphanol tartrate inj 2mg/ml
CODEINE SULFATE TABS 60MG
codeine sulfate tabs 30mg
DILAUDID-5
hydromorphone hcl tabs
hydromorphone hcl inj 500mg/50ml
meperidine hcl inj 100mg/ml, 25mg/ml, 50mg/ml
meperitab
nalbuphine hcl
NUCYNTA
oxycodone hcl soln
oxycodone hcl caps
oxycodone hcl conc
oxycodone hcl tabs 10mg, 20mg
oxycodone hcl tabs 15mg, 30mg, 5mg
oxymorphone hydrochloride
tramadol hcl
Anesthetics
Local Anesthetics
lidocaine hcl jelly
lidocaine hcl external soln
lidocaine hcl inj 1%
lidocaine viscous
lidocaine/prilocaine crea
lidocaine oint
LIDODERM
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-craving
CAMPRAL
disulfiram
naltrexone hcl
Anti-Addiction/ Substance Abuse Treatment Agents
SUBOXONE
Opioid Antagonists
buprenorphine hcl
naloxone hcl
Drug
Tier Requirements/Limits
2
2
3
2
4
1
1
2
2
1
4
1
1
2
1
1
2
1
MO GC
MO GC
MO
MO GC
1
1
1
1
2
1
4
MO GC
MO GC
MO GC
MO GC
B/D MO GC
B/D MO GC
MO GC
MO GC
PA MO GC
PA MO GC
MO GC
QL (180 EA per 30 days)
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
4
2
2
MO GC
MO GC
4
QL (90 EA per 30 days)
2
1
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 4 of 73
Drug Name
SUBOXONE FILM 4MG, 1MG
SUBOXONE FILM 12MG, 3MG
Smoking Cessation Agents
CHANTIX STARTING MONTH PAK
CHANTIX TABS 1MG
CHANTIX TABS 0.5MG
NICOTROL NS
Anti-inflammatory Agents
Nonsteroidal Anti-inflammatory Drugs
naproxen
Antibacterials
Aminoglycosides
amikacin sulfate inj 1gm/4ml
gentak oint
gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml, 0.9%,
1mg/ml, 0.9%
gentamicin sulfate crea, inj, oint, ophthalmic soln
isotonic gentamicin inj 0.8mg/ml, 0.9%
KANAMYCIN SULFATE
neomycin sulfate
paromomycin sulfate
TOBI
TOBRADEX OINT
tobramycin sulfate ophthalmic soln
tobramycin sulfate inj 10mg/ml, 80mg/2ml
TOBREX OINT
Antibacterials, Other
acetic acid
alcohol preps pads
ALTABAX
bacitracin oint
BACTROBAN NASAL
BACTROBAN CREA
CLEOCIN PEDIATRIC GRANULES
CLEOCIN SUPP
clindamycin hcl caps 150mg, 300mg
clindamycin phosphate add-vantage
clindamycin phosphate crea, gel, lotn, soln, swab
clindamycin phosphate foam
Drug
Tier Requirements/Limits
5 QL (180 EA per 30 days)
5 QL (90 EA per 30 days)
4
4
4
3
QL (53 EA per 28 days) PA
QL (56 EA per 30 days) PA
QL (60 EA per 30 days) PA
MO
1
MO GC
1
1
1
MO GC
MO GC
MO GC
1
1
4
1
1
4
4
1
1
4
MO GC
MO GC
1
1
4
2
4
4
4
4
1
1
1
2
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 5 of 73
Drug Name
CUBICIN
LINCOCIN
MACRODANTIN CAPS 25MG
methenamine hippurate
METROGEL
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole crea, gel, lotn, tabs
metronidazole caps
MONUROL
mupirocin oint
NITROFURANTOIN
nitrofurantoin macrocrystalline caps 50mg
nitrofurantoin monohydrate
SULFAMYLON CREA
trimethoprim
TYGACIL
VANCOMYCIN HCL CAPS
vancomycin hcl inj 1000mg, 10gm, 500mg
vandazole
XIFAXAN TABS 200MG
XIFAXAN TABS 550MG
ZYVOX INJ
ZYVOX SUSR
ZYVOX TABS
Antibacterials
COLISTIMETHATE SODIUM
SYNERCID
Beta-lactam, Cephalosporins
cefaclor caps
cefadroxil
cefazolin sodium inj 10gm, 1gm, 500mg
cefdinir
cefepime inj 1gm, 2gm
cefotaxime sodium inj 10gm, 1gm, 2gm
cefotetan
cefoxitin sodium inj 1gm, 4%, 2gm
cefpodoxime proxetil
Drug
Tier
5
3
4
2
4
2
1
1
2
4
1
4
2
2
4
1
4
5
2
1
4
5
5
5
5
Requirements/Limits
MO
PA
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA MO GC
PA MO GC
MO GC
B/D MO GC
MO GC
QL (9 EA per 30 days)
QL (60 EA per 30 days)
PA
QL (1800 ML per 30 days) PA
QL (56 EA per 30 days) PA
4
5
B/D
1
2
2
2
2
2
2
2
2
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 6 of 73
Drug Name
cefprozil
ceftazidime inj 1gm, 2gm
ceftriaxone sodium inj 10gm, 250mg, 500mg
cefuroxime axetil tabs
cefuroxime sodium inj 1.5gm, 7.5gm, 750mg
cephalexin caps, susr
SPECTRACEF TABS 400MG
SUPRAX CHEW, TABS
SUPRAX SUSR 100MG/5ML
TEFLARO INJ 400MG
Beta-lactam, Other
aztreonam inj 1gm
CAYSTON
DORIBAX INJ 500MG
imipenem/cilastatin
INVANZ
meropenem inj 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium er
amoxicillin/clavulanate potassium chew
amoxicillin/clavulanate potassium susr 250mg/5ml,
62.5mg/5ml, 400mg/5ml, 57mg/5ml, 600mg/5ml, 42.9mg/5ml
amoxicillin/clavulanate potassium tabs 250mg, 125mg
amoxicillin/potassium clavulanate tabs
amoxicillin/potassium clavulanate susr 200mg/5ml,
28.5mg/5ml
amoxicillin chew 250mg
amoxicillin caps, susr, tabs
ampicillin sodium inj 125mg, 1gm
ampicillin-sulbactam inj 10gm, 5gm, 2gm, 1gm
ampicillin caps
BICILLIN C-R INJ 300000UNIT/ML, 300000UNIT/ML
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium inj 1gm
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJ 0, 60000UNIT/ML
penicillin g potassium inj 5mu
penicillin g sodium
Drug
Tier
2
2
2
2
2
1
4
4
4
4
Requirements/Limits
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
B/D
2
5
4
2
4
2
MO GC
QL (84 ML per 28 days) PA
2
2
2
MO GC
MO GC
MO GC
2
2
2
MO GC
MO GC
MO GC
1
1
1
2
1
4
4
1
1
3
MO GC
MO GC
MO GC
MO GC
MO GC
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 7 of 73
Drug Name
penicillin v potassium
piperacillin sodium/tazobactam sodium inj 3gm, 0.375gm
Macrolides
AKNE-MYCIN
AZASITE
azithromycin susr, tabs
azithromycin inj 500mg
clarithromycin
clarithromycin er
DIFICID
E.E.S. 400
E.E.S. GRANULES
ery
ERY-TAB
ERYPED 200
ERYPED 400
ERYTHROCIN STEARATE
erythromycin ethylsuccinate
erythromycin gel, oint, soln
ZITHROMAX PACK
Quinolones
AVELOX
BESIVANCE
CILOXAN OINT
ciprofloxacin er
ciprofloxacin hcl
ciprofloxacin inj 400mg/40ml
CIPRO SUSR 500MG/5ML
FACTIVE
levofloxacin
levofloxacin in d5w inj 5%, 500mg/100ml
MOXEZA
ofloxacin ophthalmic soln, otic soln
ofloxacin tabs
VIGAMOX
ZYMAXID
Sulfonamides
silver sulfadiazine
Drug
Tier Requirements/Limits
1 MO GC
2 MO GC
4
4
2
2
2
2
4
3
3
2
4
4
4
3
1
1
4
4
4
4
2
1
2
4
4
1
1
4
1
2
4
4
1
MO GC
MO GC
MO GC
MO GC
PA
MO
MO
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 8 of 73
Drug Name
sodium sulfacetamide
SSD
sulfacetamide sodium susp
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
THERMAZENE
Tetracyclines
DEMECLOCYCLINE HCL
doxycycline hyclate caps
doxycycline hyclate inj
doxycycline hyclate tabs 100mg
doxycycline hyclate tabs 20mg
doxycycline hyclate tbec 150mg
doxycycline monohydrate tabs 150mg, 50mg
doxycycline caps 75mg
minocycline hcl caps
tetracycline hcl
Anticonvulsants
Anticonvulsants, Other
levetiracetam er
levetiracetam oral soln, tabs
levetiracetam inj 500mg/5ml
ONFI
phenobarbital elix
phenobarbital tabs 32.4mg
phenobarbital tabs 100mg, 15mg, 60mg
phenobarbital tabs 16.2mg, 30mg, 64.8mg, 97.2mg
POTIGA
Calcium Channel Modifying Agents
CELONTIN
ethosuximide
LYRICA SOLN
LYRICA CAPS 225MG, 300MG
LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG,
75MG
zonisamide
Gamma-aminobutyric Acid (GABA) Augmenting Agents
Drug
Tier
1
3
2
1
1
1
3
4
1
2
1
2
2
2
2
1
1
2
1
2
4
1
Requirements/Limits
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
1
1
1
5
MO GC
MO GC
MO GC
QL (60 EA per 30 days)
QL (1500 ML per 30 days) PA MO
GC
QL (30 EA per 30 days) PA MO GC
QL (90 EA per 30 days) PA MO GC
QL (90 EA per 30 days) PA MO GC
PA
4
2
3
3
3
MO GC
QL (450 ML per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
1
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 9 of 73
Drug
Drug Name
Tier Requirements/Limits
divalproex sodium
1 MO GC
divalproex sodium dr
1 MO GC
divalproex sodium er
1 MO GC
gabapentin
1 MO GC
GABITRIL TABS 12MG
4 QL (120 EA per 30 days)
GABITRIL TABS 2MG
4 QL (30 EA per 30 days)
GABITRIL TABS 16MG, 4MG
4 QL (60 EA per 30 days)
primidone
1 MO GC
SABRIL TABS
4 QL (180 EA per 30 days) LA
SABRIL PACK
5 QL (180 EA per 30 days)
STAVZOR CPDR 500MG
4
tiagabine hydrochloride
2 QL (60 EA per 30 days) MO
valproate sodium
1 MO GC
valproic acid
1 MO GC
Glutamate Reducing Agents
felbamate
2 MO GC
LAMICTAL ODT TBDP 200MG
4 QL (30 EA per 30 days)
LAMICTAL ODT TBDP 100MG, 25MG
4 QL (60 EA per 30 days)
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE
4 QL (49 EA per 30 days)
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT
4 QL (98 EA per 30 days)
TAKING VALPROATE
LAMICTAL STARTER/TAKING VALPROATE
4 QL (35 EA per 30 days)
LAMICTAL XR KIT 0
4 QL (35 EA per 35 days)
LAMICTAL XR TB24 250MG
4 QL (30 EA per 30 days)
LAMICTAL XR TB24 100MG, 25MG, 50MG
4 QL (60 EA per 30 days)
LAMICTAL XR TB24 200MG
4 QL (90 EA per 30 days)
lamotrigine
1 MO GC
lamotrigine er tb24 250mg, 300mg
2 QL (30 EA per 30 days) MO GC
lamotrigine er tb24 100mg, 25mg, 50mg
2 QL (60 EA per 30 days) MO GC
lamotrigine er tb24 200mg
2 QL (90 EA per 30 days) MO GC
topiramate
1 MO GC
Sodium Channel Agents
BANZEL SUSP
5 QL (2400 ML per 30 days)
BANZEL TABS 200MG
4 QL (60 EA per 30 days)
BANZEL TABS 400MG
5 QL (240 EA per 30 days)
carbamazepine er
2 MO GC
carbamazepine chew, susp
1 MO GC
DILANTIN
4
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 10 of 73
Drug Name
DILANTIN INFATABS
epitol
EQUETRO CP12 100MG, 300MG
EQUETRO CP12 200MG
oxcarbazepine tabs
PEGANONE
PHENYTEK
phenytoin sodium extended
phenytoin susp
phenytoin chew
TEGRETOL
TEGRETOL-XR
TRILEPTAL SUSP
VIMPAT INJ
VIMPAT ORAL SOLN
VIMPAT TABS
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates
Cholinesterase Inhibitors
donepezil hcl
EXELON PT24
EXELON SOLN
galantamine hydrobromide
rivastigmine tartrate
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TITRATION PAK
NAMENDA SOLN
NAMENDA TABS
Antidepressants
Antidepressants, Other
APLENZIN
budeprion sr
buproban
bupropion hcl
bupropion hcl sr tb12 200mg
FORFIVO XL
maprotiline hcl
mirtazapine
Drug
Tier
4
1
4
4
1
4
4
1
1
2
4
4
4
4
4
4
Requirements/Limits
MO GC
QL (240 EA per 30 days)
MO GC
MO GC
MO GC
MO
QL (1200 ML per 30 days)
QL (60 EA per 30 days)
2
MO GC
1
3
4
2
2
MO GC
QL (30 EA per 30 days) MO
3
3
3
QL (49 EA per 30 days) MO
QL (300 ML per 30 days) MO
QL (60 EA per 30 days) MO
4
1
1
1
1
4
2
1
ST
MO GC
MO GC
MO GC
MO GC
QL (30 EA per 30 days)
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 11 of 73
Drug Name
mirtazapine odt tbdp 30mg, 45mg
nefazodone hcl
SEROQUEL XR TB24 150MG, 200MG
SEROQUEL XR TB24 300MG, 400MG, 50MG
trazodone hcl tabs 100mg, 150mg, 50mg
trazodone hcl tabs 300mg
VIIBRYD TABS
VIIBRYD KIT
Antidepressants
chlordiazepoxide/amitriptyline
fluoxetine hcl
olanzapine/fluoxetine caps 25mg, 3mg
olanzapine/fluoxetine caps 25mg, 12mg, 50mg, 12mg, 50mg,
6mg
olanzapine/fluoxetine caps 25mg, 6mg
perphenazine/amitriptyline
SYMBYAX CAPS 25MG, 3MG
SYMBYAX CAPS 50MG, 6MG
SYMBYAX CAPS 25MG, 6MG
SYMBYAX CAPS 25MG, 12MG, 50MG, 12MG
Monoamine Oxidase Inhibitors
EMSAM PT24 6MG/24HR, 9MG/24HR
EMSAM PT24 12MG/24HR
MARPLAN
phenelzine sulfate
tranylcypromine sulfate
Serotonin/ Norepinephrine Reuptake Inhibitors
citalopram hydrobromide
CYMBALTA CPEP 60MG
CYMBALTA CPEP 20MG, 30MG
escitalopram oxalate soln
escitalopram oxalate tabs 10mg
escitalopram oxalate tabs 20mg, 5mg
fluoxetine hcl
fluvoxamine maleate
paroxetine hcl
paroxetine hcl er
PAXIL
Drug
Tier
1
2
4
4
1
2
4
4
Requirements/Limits
MO GC
MO GC
QL (30 EA per 30 days)
QL (60 EA per 30 days)
MO GC
MO GC
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
2
2
2
2
PA MO GC
QL (30 EA per 30 days) MO GC
QL (30 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
2
1
4
4
4
5
QL (90 EA per 30 days) MO
MO GC
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
4
5
4
1
2
QL (30 EA per 30 days)
QL (30 EA per 30 days)
MO GC
MO GC
1
4
4
2
2
2
1
1
1
2
4
MO GC
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (600 ML per 30 days) MO GC
MO GC
QL (30 EA per 30 days) MO GC
MO GC
MO GC
MO GC
MO GC
ST
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 12 of 73
Drug Name
PEXEVA
PRISTIQ
sertraline hcl
venlafaxine hcl
VENLAFAXINE HCL ER
Tricyclics
amitriptyline hcl
amoxapine tabs 100mg, 25mg, 50mg
clomipramine hcl
desipramine hcl
doxepin hcl
imipramine hcl
IMIPRAMINE PAMOATE CAPS 125MG
imipramine pamoate caps 100mg, 150mg, 75mg
nortriptyline hcl caps
protriptyline hcl
SILENOR
trimipramine maleate
Antiemetics
Antiemetics, Other
chlorpromazine hcl
compro
diphenhydramine hcl caps 50mg
hydroxyzine hcl
hydroxyzine pamoate
meclizine hcl
metoclopramide hcl
perphenazine
phenadoz
prochlorperazine edisylate
prochlorperazine maleate
promethazine hcl
promethegan supp 25mg, 50mg
TRANSDERM-SCOP
trimethobenzamide hcl caps
Emetogenic Therapy Adjuncts
ALOXI
DRONABINOL CAPS 10MG
Drug
Tier
4
4
1
1
4
Requirements/Limits
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
MO GC
MO GC
ST
1
1
1
2
1
1
4
2
1
2
4
2
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
QL (30 EA per 30 days)
MO GC
MO GC
MO GC
1
1
1
1
1
1
1
1
1
1
1
1
1
4
1
MO GC
MO GC
PA MO GC
PA MO GC
PA MO GC
MO GC
MO GC
MO GC
PA MO GC
MO GC
MO GC
PA MO GC
PA MO GC
4
5
MO GC
PA MO GC
QL (60 EA per 30 days) B/D
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 13 of 73
Drug Name
dronabinol caps 2.5mg, 5mg
EMEND CAPS 125MG, 40MG
EMEND CAPS 80MG
EMEND CAPS 0
granisetron hcl tabs
granisetron hcl inj 1mg/ml
ondansetron hcl soln
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg, 8mg
ondansetron odt tbdp 8mg
ondansetron odt tbdp 4mg
SANCUSO
Antifungals
Antifungals
ABELCET
AMBISOME
AMPHOTEC INJ 50MG
amphotericin b
ANCOBON
CANCIDAS INJ 70MG
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
clotrimazole soln, troc
econazole nitrate
ERTACZO
EXELDERM
fluconazole
fluconazole in dextrose inj 56mg/ml, 400mg/200ml
flucytosine
GRIS-PEG
griseofulvin microsize tabs
griseofulvin microsize susp
Drug
Tier Requirements/Limits
2 QL (60 EA per 30 days) B/D MO
GC
4 QL (1 EA per 1 days) B/D
4 QL (2 EA per 1 days) B/D
4 QL (3 EA per 1 days) B/D
2 QL (60 EA per 30 days) B/D MO
GC
2 QL (14 ML per 30 days) B/D MO
GC
2 QL (450 ML per 30 days) B/D MO
GC
2 B/D MO GC
2 QL (9 EA per 3 days) B/D MO GC
2 QL (45 EA per 30 days) B/D MO
GC
2 QL (9 EA per 3 days) B/D MO GC
5 QL (4 EA per 28 days) B/D
4
4
4
2
4
5
1
1
1
1
1
4
4
1
1
2
4
2
2
B/D
B/D
B/D
B/D MO GC
PA
MO GC
PA MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 14 of 73
Drug Name
griseofulvin ultramicrosize
itraconazole
ketoconazole crea, sham, tabs
ketoconazole foam
MENTAX
miconazole 3
MYCAMINE
NAFTIN GEL
NAFTIN CREA 1%
NATACYN
NOXAFIL
nystatin crea, oint, susp, tabs
nystop
ONMEL
OXISTAT
pedi-dri
SPORANOX SOLN
terbinafine hcl tabs
terconazole crea 0.8%
terconazole crea 0.4%
terconazole supp
VFEND IV
voriconazole inj
VORICONAZOLE TABS 50MG
VORICONAZOLE TABS 200MG
zazole crea
ZOLINZA
Antigout Agents
Antigout Agents
allopurinol
COLCRYS
probenecid
probenecid/colchicine
ULORIC
Antimigraine Agents
Ergot Alkaloids
dihydroergotamine mesylate
MIGERGOT
Drug
Tier Requirements/Limits
2 MO
2 QL (120 EA per 30 days) PA MO
GC
1 MO GC
2 MO GC
4
1 MO GC
5
4
4
4
5 PA
1 MO GC
1 MO GC
4 PA
4
1 MO GC
5 PA
1 QL (30 EA per 30 days) PA MO GC
1 MO GC
1 MO GC
1 MO GC
4 PA
2 PA MO GC
5 QL (120 EA per 30 days) PA
5 QL (60 EA per 30 days) PA
1 MO GC
5 QL (120 EA per 30 days) PA
1
4
1
1
4
MO GC
QL (120 EA per 30 days)
MO GC
MO GC
PA
2
4
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 15 of 73
Drug Name
MIGRANAL
Prophylactic
BOTOX INJ 100UNIT
timolol maleate
Serotonin (5-HT) 1b/1d Receptor Agonists
AXERT TABS 12.5MG
FROVA
IMITREX SOLN
MAXALT
MAXALT-MLT
naratriptan hcl
RELPAX
rizatriptan benzoate
sumatriptan succinate tabs
sumatriptan succinate inj 6mg/0.5ml
ZOMIG ZMT
ZOMIG SOLN
ZOMIG TABS
Antimyasthenic Agents
Parasympathomimetics
MESTINON TIMESPAN
MESTINON SYRP
pyridostigmine bromide
Antimycobacterials
Antimycobacterials, Other
ACZONE
DAPSONE
MYCOBUTIN
Antituberculars
ethambutol hcl
isoniazid tabs
rifampin
RIFATER
Antineoplastics
Alkylating Agents
CEENU
cyclophosphamide tabs
HEXALEN
Drug
Tier Requirements/Limits
5 QL (12 ML per 30 days)
4
1
PA
MO GC
4
4
4
4
4
1
4
2
1
2
4
4
4
QL (24 EA per 28 days)
QL (12 EA per 30 days)
QL (12 EA per 30 days)
QL (12 EA per 30 days)
MO GC
QL (9 EA per 30 days)
QL (12 EA per 28 days) MO GC
MO GC
MO GC
QL (9 EA per 30 days)
QL (6 EA per 30 days)
QL (9 EA per 30 days)
4
4
1
MO GC
4
3
4
PA
MO
1
1
1
4
MO GC
MO GC
MO GC
4
2
5
B/D MO GC
PA
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 16 of 73
Drug Name
LEUKERAN
MATULANE
Antiangiogenic Agents
REVLIMID CAPS 15MG, 25MG
REVLIMID CAPS 10MG, 5MG
THALOMID CAPS 100MG, 50MG
THALOMID CAPS 150MG, 200MG
Antiestrogens/Modifiers
EMCYT
FARESTON
tamoxifen citrate
Antimetabolites
DROXIA CAPS 300MG
GEMCITABINE HCL INJ 1GM
hydroxyurea
TABLOID
Antineoplastics, Other
amifostine
COMETRIQ
ICLUSIG TABS 45MG
ICLUSIG TABS 15MG
leucovorin calcium tabs
leucovorin calcium inj 100mg, 350mg
mitoxantrone hcl
SYNRIBO
YERVOY
ZALTRAP INJ 100MG/4ML
ZELBORAF
Antineoplastics
adriamycin inj 2mg/ml
ALIMTA
ARRANON
AVASTIN
CAMPATH
carboplatin inj 150mg/15ml
CYTARABINE AQUEOUS
DACOGEN
dexrazoxane inj 500mg
DOCETAXEL INJ 80MG/8ML
Drug
Tier Requirements/Limits
4
5
5
5
5
5
QL (21 EA per 28 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
4
4
1
PA
4
5
1
4
MO GC
MO GC
1
5
5
5
1
1
1
5
5
5
5
MO GC
PA
PA
QL (60 EA per 30 days) PA
MO GC
MO GC
MO GC
PA
PA
PA
QL (240 EA per 30 days) PA
2
5
5
5
5
2
4
5
5
5
MO GC
PA
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 17 of 73
Drug Name
DOXIL
ELOXATIN INJ 100MG/20ML
ERBITUX
ERIVEDGE
FASLODEX
HERCEPTIN
INLYTA
irinotecan inj 100mg/5ml
IXEMPRA KIT INJ 45MG
JEVTANA
mesna
MESNEX TABS
mitomycin inj 20mg
MUSTARGEN
PACLITAXEL INJ 300MG/50ML
PERJETA
PROLEUKIN
STIVARGA
TAXOTERE INJ 80MG/4ML
TREANDA
VECTIBIX
VELCADE
VIDAZA
VINCASAR PFS
XTANDI
Aromatase Inhibitors, 3rd Generation
anastrozole
exemestane
letrozole
Enzyme Inhibitors
ETOPOSIDE INJ
JAKAFI
Molecular Target Inhibitors
AFINITOR TABS 7.5MG
AFINITOR TABS 10MG
AFINITOR TABS 5MG
BOSULIF
CAPRELSA TABS 100MG
Drug
Tier
5
5
5
5
4
5
5
2
5
5
2
5
2
4
4
5
5
5
5
5
5
5
5
4
5
Requirements/Limits
PA
PA
PA
MO GC
PA
PA
MO GC
MO GC
PA
PA
PA
PA
PA
QL (120 EA per 30 days) PA
1
2
1
MO GC
MO GC
MO GC
3
3
MO
QL (60 EA per 30 days) PA MO
5
5
5
5
5
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
PA
QL (60 EA per 30 days) PA LA
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 18 of 73
Drug Name
CAPRELSA TABS 300MG
GLEEVEC TABS 400MG
GLEEVEC TABS 100MG
NEXAVAR
SPRYCEL TABS 20MG
SPRYCEL TABS 140MG, 80MG
SPRYCEL TABS 100MG, 50MG, 70MG
SUTENT CAPS 25MG, 50MG
SUTENT CAPS 12.5MG
TARCEVA TABS 25MG
TARCEVA TABS 100MG, 150MG
TASIGNA
TYKERB
VOTRIENT
XALKORI
Monoclonal Antibodies
ARZERRA INJ 100MG/5ML
RITUXAN
Retinoids
PANRETIN
TARGRETIN
TRETINOIN CAPS
tretinoin crea, gel
Antiparasitics
Anthelmintics
ALBENZA
BILTRICIDE
STROMECTOL
Antiprotozoals
ALINIA TABS
atovaquone/proguanil hcl tabs 250mg, 100mg
chloroquine phosphate
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
MEPRON
NEBUPENT
QUALAQUIN
quinine sulfate
Drug
Tier
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Requirements/Limits
QL (90 EA per 90 days) PA LA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA LA
QL (150 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (90 EA per 90 days) PA
QL (120 EA per 30 days) PA
QL (540 EA per 90 days) PA LA
QL (360 EA per 90 days) PA
QL (60 EA per 30 days) PA
5
5
PA
PA
5
5
3
2
PA
PA
MO
PA MO GC
3
3
3
MO
MO
MO
4
2
1
4
1
2
5
4
4
2
MO GC
MO GC
MO GC
MO GC
B/D
QL (42 EA per 30 days)
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 19 of 73
Drug Name
tinidazole
Pediculicides/ Scabicides
EURAX
LINDANE SHAM
lindane lotn
malathion
permethrin
SKLICE
Antiparkinson Agents
Anticholinergics
benztropine mesylate
trihexyphenidyl hcl tabs
Antiparkinson Agents, Other
amantadine hcl
COMTAN
TASMAR
Antiparkinson Agents
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
Dopamine Agonists
APOKYN
bromocriptine mesylate
pramipexole dihydrochloride
ropinirole er
ropinirole hcl
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa er
LODOSYN
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
selegiline hcl
ZELAPAR
Antipsychotics
Drug
Tier Requirements/Limits
2 MO GC
4
4
2
2
1
4
MO GC
MO GC
MO GC
1
1
MO GC
MO GC
1
4
5
MO GC
QL (240 EA per 30 days)
QL (90 EA per 30 days)
4
4
4
4
4
4
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
5
2
1
2
1
QL (60 ML per 30 days) PA LA
MO GC
MO GC
MO GC
MO GC
1
1
4
MO GC
MO GC
4
2
4
QL (30 EA per 30 days)
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 20 of 73
Drug Name
1st Generation/ Typical
fluphenazine decanoate
fluphenazine hcl
haloperidol
haloperidol decanoate
haloperidol lactate
loxapine succinate
ORAP
thioridazine hcl
thiothixene
trifluoperazine hcl
2nd Generation/ Atypical
ABILIFY DISCMELT TBDP 10MG
ABILIFY DISCMELT TBDP 15MG
ABILIFY INJ
ABILIFY ORAL SOLN
ABILIFY TABS 10MG, 15MG, 2MG, 5MG
ABILIFY TABS 20MG, 30MG
FANAPT TABS 1MG, 2MG, 4MG
FANAPT TABS 10MG, 12MG, 6MG, 8MG
GEODON
INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML
INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML,
234MG/1.5ML
INVEGA TB24 1.5MG, 3MG
INVEGA TB24 6MG
INVEGA TB24 9MG
LATUDA TABS 120MG, 20MG, 80MG
LATUDA TABS 40MG
olanzapine
olanzapine odt
quetiapine fumarate
RISPERDAL CONSTA INJ 12.5MG, 25MG
RISPERDAL CONSTA INJ 37.5MG
RISPERDAL CONSTA INJ 50MG
risperidone
risperidone odt
SAPHRIS
ziprasidone hcl
Drug
Tier Requirements/Limits
1
1
1
1
1
2
3
1
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO
PA MO GC
MO GC
MO GC
4
5
4
4
4
5
4
4
4
4
5
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (900 ML per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (300 EA per 30 days)
QL (1 ML per 28 days)
QL (1 ML per 28 days)
4
4
5
4
4
2
2
2
4
5
5
1
1
4
2
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (90 EA per 30 days) ST
MO GC
MO GC
MO GC
QL (2 EA per 28 days)
QL (1 EA per 28 days)
QL (2 EA per 28 days)
MO GC
MO GC
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 21 of 73
Drug Name
Treatment-Resistant
clozapine
FAZACLO TBDP 100MG, 25MG
Antispasticity Agents
Antispasticity Agents
baclofen
dantrolene sodium caps
tizanidine hcl
XEOMIN
Antivirals
Anti-cytomegalovirus (CMV) Agents
CIDOFOVIR
foscarnet sodium
ganciclovir
VALCYTE TABS
ZIRGAN
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors
EDURANT
INTELENCE TABS 100MG
INTELENCE TABS 200MG
nevirapine tabs
RESCRIPTOR TABS 200MG
RESCRIPTOR TABS 100MG
SUSTIVA
VIRAMUNE XR
VIRAMUNE SUSP
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors
abacavir
COMPLERA
didanosine
EMTRIVA
EPIVIR SOLN
EPZICOM
lamivudine
LAMIVUDINE/ZIDOVUDINE
RETROVIR IV INFUSION
Drug
Tier Requirements/Limits
2
4
MO GC
1
2
1
4
MO GC
MO GC
MO GC
PA
5
2
2
5
4
MO GC
B/D MO GC
QL (84 EA per 30 days)
5
5
5
2
3
4
4
4
4
2
5
2
4
4
5
2
5
4
QL (120 EA per 30 days)
QL (60 EA per 30 days)
MO GC
MO
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 22 of 73
Drug Name
stavudine solr
stavudine caps
TRIZIVIR
TRUVADA
VIDEX PEDIATRIC SOLR 2GM
VIREAD POWD
VIREAD TABS
ZERIT SOLR
ZIAGEN
zidovudine
Anti-HIV Agents, Other
FUZEON INJ 90MG
ISENTRESS CHEW
ISENTRESS TABS
SELZENTRY TABS 300MG
SELZENTRY TABS 150MG
STRIBILD
Anti-HIV Agents, Protease Inhibitors
APTIVUS SOLN
APTIVUS CAPS
CRIXIVAN CAPS 400MG
INVIRASE CAPS
INVIRASE TABS
KALETRA SOLN
KALETRA TABS 100MG, 25MG
KALETRA TABS 200MG, 50MG
LEXIVA SUSP
LEXIVA TABS
NORVIR
PREZISTA TABS 75MG
PREZISTA TABS 150MG, 400MG, 600MG, 800MG
REYATAZ CAPS 100MG
REYATAZ CAPS 150MG, 200MG, 300MG
VIRACEPT
Anti-influenza Agents
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPS 45MG, 75MG
Antihepatitis Agents
Drug
Tier
2
2
5
5
4
4
5
4
4
1
5
3
5
5
5
5
5
5
3
4
5
5
4
5
4
5
4
4
5
4
5
5
4
2
4
Requirements/Limits
MO GC
MO GC
MO GC
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (120 EA per 30 days)
MO
QL (60 EA per 180 days)
MO GC
QL (28 EA per 180 days)
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 23 of 73
Drug Name
BARACLUDE SOLN
BARACLUDE TABS 1MG
BARACLUDE TABS 0.5MG
EPIVIR HBV
HEPSERA
INCIVEK
INTRON-A W/DILUENT INJ 10MU
INTRON-A INJ 6000000UNIT/ML
PEG-INTRON REDIPEN
PEG-INTRON INJ 50MCG/0.5ML
PEGASYS PROCLICK INJ 135MCG/0.5ML
PEGASYS INJ 180MCG/0.5ML
PEGASYS INJ 180MCG/ML
RIBAPAK TABS 400MG
ribasphere caps
RIBASPHERE TABS 200MG
RIBASPHERE TABS 400MG, 600MG
ribavirin
SYLATRON
TYZEKA
VICTRELIS
VIRAZOLE
Antiherpetic Agents
acyclovir
acyclovir sodium inj 500mg
DENAVIR
famciclovir
trifluridine
valacyclovir hcl
ZOVIRAX CREA
ZOVIRAX OINT
Antivirals
ATRIPLA
Anxiolytics
Anxiolytics, Other
alprazolam er tb24 0.5mg
alprazolam intensol
alprazolam odt tbdp 0.25mg, 0.5mg
Drug
Tier
4
5
5
4
5
5
4
4
5
5
5
5
5
5
2
4
5
2
5
5
5
5
1
1
4
2
2
2
4
4
Requirements/Limits
QL (600 ML per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (504 EA per 84 days) PA
PA
PA
QL (4 EA per 28 days) ST PA
QL (4 EA per 28 days) ST PA
QL (4 ML per 28 days) PA
QL (2 EA per 28 days) PA
QL (4 ML per 28 days) PA
PA
PA MO GC
PA
PA
PA MO GC
QL (4 EA per 28 days) PA
QL (30 EA per 30 days)
QL (360 EA per 30 days) PA
B/D
MO GC
MO GC
QL (5 GM per 30 days)
MO GC
MO GC
MO GC
QL (15 GM per 30 days)
QL (30 GM per 30 days)
5
2
2
2
QL (120 EA per 30 days) MO GC
QL (60 ML per 30 days) MO GC
QL (120 EA per 30 days) MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 24 of 73
Drug Name
alprazolam odt tbdp 1mg, 2mg
alprazolam xr tb24 1mg, 2mg, 3mg
alprazolam tabs 0.25mg, 0.5mg
alprazolam tabs 1mg, 2mg
buspirone hcl tabs 10mg, 15mg, 30mg, 5mg
buspirone hcl tabs 7.5mg
clonazepam odt tbdp 2mg
Drug
Tier
2
2
2
2
1
2
2
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg
clonazepam tabs 2mg
2
1
clonazepam tabs 0.5mg, 1mg
clorazepate dipotassium
DIAZEPAM GEL
diazepam soln
1
2
4
1
diazepam tabs 10mg
1
diazepam tabs 2mg, 5mg
lorazepam intensol
lorazepam tabs 0.5mg
lorazepam tabs 2mg
lorazepam tabs 1mg
meprobamate
temazepam
SSRIs/ SNRIs
venlafaxine hcl er
Bipolar Agents
Mood Stabilizers
carbamazepine er
lithium carbonate
lithium carbonate er
lithium citrate
Blood Glucose Regulators
Antidiabetic Agents
acarbose
ACTOS
AVANDIA TABS 8MG
AVANDIA TABS 2MG, 4MG
1
2
2
2
2
2
2
Requirements/Limits
QL (60 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (120 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
MO GC
MO GC
QL (300 EA per 30 days) PA MO
GC
QL (90 EA per 30 days) PA MO GC
QL (300 EA per 30 days) PA MO
GC
QL (90 EA per 30 days) PA MO GC
QL (90 EA per 30 days) PA MO GC
PA
QL (1200 ML per 30 days) PA MO
GC
QL (120 EA per 30 days) PA MO
GC
QL (60 EA per 30 days) PA MO GC
QL (45 ML per 30 days) MO GC
QL (180 EA per 30 days) MO GC
QL (30 EA per 30 days) MO GC
QL (90 EA per 30 days) MO GC
PA MO GC
QL (30 EA per 30 days) MO GC
1
MO GC
2
1
1
1
MO GC
MO GC
MO GC
MO GC
1
4
4
4
QL (90 EA per 30 days) MO GC
QL (30 EA per 30 days) GCD
QL (30 EA per 30 days) GCD
QL (60 EA per 30 days) GCD
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 25 of 73
Drug Name
BYDUREON
BYETTA INJ 10MCG/0.04ML
BYETTA INJ 5MCG/0.02ML
chlorpropamide tabs 100mg
chlorpropamide tabs 250mg
CYCLOSET
glimepiride tabs 2mg
glimepiride tabs 1mg
glimepiride tabs 4mg
glipizide er tb24 5mg
glipizide er tb24 2.5mg
glipizide er tb24 10mg
glipizide tabs 10mg
glipizide tabs 5mg
glyburide micronized tabs 3mg
glyburide micronized tabs 1.5mg
glyburide micronized tabs 6mg
glyburide tabs 5mg
glyburide tabs 2.5mg
glyburide tabs 1.25mg
GLYSET
JANUVIA
metformin hcl er tb24 500mg
metformin hcl er tb24 750mg
metformin hcl tabs 500mg
metformin hcl tabs 1000mg
metformin hcl tabs 850mg
nateglinide
ONGLYZA TABS 5MG
ONGLYZA TABS 2.5MG
pioglitazone hcl
PRANDIN TABS 0.5MG, 1MG
PRANDIN TABS 2MG
SYMLINPEN 120
SYMLINPEN 60
tolazamide tabs 500mg
tolbutamide
Drug
Tier
3
4
4
2
2
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
3
1
1
1
1
1
1
4
4
2
4
4
4
4
1
1
Requirements/Limits
QL (4 EA per 28 days) MO
QL (2.4 ML per 28 days)
QL (4.8 ML per 28 days)
QL (210 EA per 30 days) PA MO
GC
QL (90 EA per 30 days) PA MO GC
QL (180 EA per 30 days)
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (480 EA per 30 days) MO GC
QL (90 EA per 30 days)
QL (30 EA per 30 days) MO GCD
QL (120 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (150 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (90 EA per 30 days) MO GC
QL (90 EA per 30 days) MO GC
QL (30 EA per 30 days) GCD
QL (60 EA per 30 days) GCD
QL (30 EA per 30 days) MO
QL (120 EA per 30 days)
QL (240 EA per 30 days)
QL (180 EA per 30 days) MO GC
QL (180 EA per 30 days) MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 26 of 73
Drug Name
TRADJENTA
VICTOZA
WELCHOL
Blood Glucose Regulators
ACTOPLUS MET
ACTOPLUS MET XR
AVANDAMET
AVANDARYL
glipizide/metformin hcl tabs 2.5mg, 500mg, 5mg, 500mg
glipizide/metformin hcl tabs 2.5mg, 250mg
glyburide/metformin hcl tabs 2.5mg, 500mg, 5mg, 500mg
glyburide/metformin hcl tabs 1.25mg, 250mg
JANUMET
JANUMET XR
KOMBIGLYZE XR TB24 1000MG, 5MG, 500MG, 5MG
KOMBIGLYZE XR TB24 1000MG, 2.5MG
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
PRANDIMET
Glycemic Agents
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
Insulins
APIDRA
APIDRA SOLOSTAR
bd insulin syringe safetyglide/1ml/29g x 1/2"
bd insulin syringe ultrafine/0.3ml/31g x 5/16"
bd insulin syringe ultrafine/0.5ml/30g x 1/2"
bd insulin syringe ultrafine/1ml/31g x 5/16"
bd pen needle/ultrafine/29g x 12.7mm
curity gauze pads 2"x2"
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN 70/30
Drug
Tier
3
4
3
Requirements/Limits
QL (30 EA per 30 days) MO
QL (18 ML per 28 days)
MO
4
4
4
4
1
1
1
1
3
3
4
4
2
2
4
GCD
GCD
GCD
GCD
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (120 EA per 30 days) MO GC
QL (240 EA per 30 days) MO GC
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
MO GC
MO GC
QL (150 EA per 30 days)
4
3
4
MO
4
4
2
2
2
2
2
2
3
3
3
3
3
3
3
GCD
GCD
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 27 of 73
Drug Name
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
Blood Products/ Modifiers/ Volume Expanders
Anticoagulants
COUMADIN
ENOXAPARIN SODIUM INJ 80MG/0.8ML
ENOXAPARIN SODIUM INJ 100MG/ML, 120MG/0.8ML,
150MG/ML
enoxaparin sodium inj 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml
FONDAPARINUX SODIUM INJ 2.5MG/0.5ML
FONDAPARINUX SODIUM INJ 10MG/0.8ML,
5MG/0.4ML, 7.5MG/0.6ML
FRAGMIN INJ 2500UNIT/0.2ML
FRAGMIN INJ 12500UNIT/0.5ML, 15000UNIT/0.6ML,
18000UNT/0.72ML, 7500UNIT/0.3ML
heparin sodium
heparin sodium/nacl 0.45%
jantoven
LOVENOX
PRADAXA
warfarin sodium
XARELTO TABS 15MG, 20MG
XARELTO TABS 10MG
Blood Formation Modifiers
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO
MO
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
MO GCD
4
4
5
QL (28 ML per 30 days)
QL (28 ML per 30 days)
2
4
5
QL (28 ML per 30 days) MO GC
QL (14 ML per 28 days)
QL (14 ML per 28 days)
4
5
QL (14 ML per 28 days)
QL (14 ML per 28 days)
1
1
1
4
4
1
3
3
B/D MO GC
B/D MO GC
MO GC
QL (28 ML per 30 days)
MO GC
QL (30 EA per 30 days) MO
QL (35 EA per 365 days) PA MO
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 28 of 73
Drug Name
anagrelide hydrochloride
ARANESP ALBUMIN FREE INJ 60MCG/ML
ARANESP ALBUMIN FREE INJ 40MCG/ML
ARANESP ALBUMIN FREE INJ 25MCG/ML
ARANESP ALBUMIN FREE INJ 500MCG/ML
ARANESP ALBUMIN FREE INJ 200MCG/ML
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML
ARANESP ALBUMIN FREE INJ 100MCG/ML
LEUKINE
NEULASTA
NEUPOGEN
PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML
PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML
PROMACTA
Blood Products/ Modifiers/ Volume Expanders
CINRYZE
NEUMEGA
Coagulants
tranexamic acid
Platelet Modifying Agents
AGGRENOX
cilostazol
clopidogrel tabs 300mg
clopidogrel tabs 75mg
dipyridamole
EFFIENT TABS 10MG
EFFIENT TABS 5MG
ticlopidine hcl
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl tabs
clonidine hcl ptwk
guanfacine hcl
methyldopa
midodrine hcl
Alpha-adrenergic Blocking Agents
DIBENZYLINE
doxazosin mesylate
Drug
Tier
2
4
4
4
5
5
5
5
5
5
5
4
Requirements/Limits
MO GC
QL (2.4 ML per 28 days) ST PA
QL (3.2 ML per 28 days) ST PA
QL (4 ML per 30 days) ST PA
QL (1 ML per 28 days) ST PA
QL (1.6 ML per 28 days) ST PA
QL (2.4 ML per 28 days) ST PA
QL (4 ML per 28 days) ST PA
PA
PA
PA
QL (12 ML per 30 days) PA
5
5
QL (12 ML per 30 days) PA
QL (30 EA per 30 days) PA
5
5
PA
PA
2
MO GC
4
1
2
2
1
4
4
1
QL (60 EA per 30 days)
MO GC
MO GC
QL (34 EA per 30 days) MO GC
PA MO GC
QL (36 EA per 30 days)
QL (43 EA per 30 days)
MO GC
1
2
1
2
2
MO GC
MO GC
MO GC
MO GC
MO GC
4
1
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 29 of 73
Drug Name
prazosin hcl
terazosin hcl
Angiotensin II Receptor Antagonists
BENICAR
DIOVAN
EDARBI
eprosartan mesylate
irbesartan
losartan potassium
MICARDIS
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl
captopril
enalapril maleate
fosinopril sodium
lisinopril
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
Antiarrhythmics
amiodarone hcl tabs 400mg
disopyramide phosphate
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR CP12 100MG
PACERONE TABS 100MG
pacerone tabs 200mg
propafenone hcl
propafenone hcl er
quinidine gluconate er
quinidine sulfate
quinidine sulfate er
sorine
sotalol hcl (af) tabs 120mg
sotalol hcl tabs 160mg, 240mg, 80mg
Drug
Tier Requirements/Limits
1 MO GC
1 MO GC
3
4
4
2
2
1
3
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) ST
MO GC
QL (30 EA per 30 days) MO GC
MO GC
QL (30 EA per 30 days) MO
1
1
1
1
1
2
2
1
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
1
1
1
1
4
4
4
1
1
2
1
1
1
1
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 30 of 73
Drug Name
TIKOSYN
Beta-adrenergic Blocking Agents
acebutolol hcl
atenolol
betaxolol hcl tabs 10mg
betaxolol hcl tabs 20mg
bisoprolol fumarate
BYSTOLIC TABS 10MG
BYSTOLIC TABS 2.5MG
BYSTOLIC TABS 20MG
BYSTOLIC TABS 5MG
carvedilol
COREG CR
INNOPRAN XL
labetalol hcl tabs
LEVATOL
metoprolol succinate er
metoprolol tartrate tabs
nadolol
pindolol
propranolol hcl er
propranolol hcl tabs
Calcium Channel Blocking Agents
afeditab cr
amlodipine besylate
cartia xt
dilt-cd cp24 120mg, 300mg
dilt-xr cp24 180mg, 240mg
diltiazem cd cp24 120mg, 240mg, 300mg
diltiazem hcl er cp24 180mg, 360mg
diltiazem hcl er cp12
diltiazem hcl tabs
DYNACIRC CR TB24 5MG
DYNACIRC CR TB24 10MG
felodipine er
isradipine
matzim la
nicardipine hcl caps
nifediac cc tb24 90mg
Drug
Tier Requirements/Limits
4
1
1
1
1
1
3
3
3
3
1
4
4
1
4
1
1
1
1
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
QL (120 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO GC
1
1
1
1
1
1
1
1
1
4
4
1
2
2
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
QL (30 EA per 30 days)
QL (60 EA per 30 days)
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 31 of 73
Drug Name
nifedical xl
nifedipine
nifedipine er
NIMODIPINE
nisoldipine
nisoldipine er
taztia xt
verapamil hcl er
verapamil hcl tabs
Cardiovascular Agents, Other
digoxin soln, tabs
LANOXIN TABS
pentoxifylline er
RANEXA
TEKTURNA
Cardiovascular Agents
ADVICOR TB24 40MG, 1000MG
ADVICOR TB24 20MG, 1000MG, 20MG, 500MG, 20MG,
750MG
ALDACTAZIDE
amiloride/hydrochlorothiazide
amlodipine besylate/benazepril hcl
amlodipine besylate/benazepril hydrochloride
AMTURNIDE
atenolol/chlorthalidone
AZOR
benazepril hcl/hydrochlorothiazide
BENICAR HCT
bisoprolol fumarate/hydrochlorothiazide
candesartan cilexetil/hydrochlorothiazide
captopril/hydrochlorothiazide
CLORPRES
enalapril maleate/hydrochlorothiazide
EXFORGE
EXFORGE HCT
fosinopril sodium/hydrochlorothiazide
irbesartan/hydrochlorothiazide
lisinopril/hydrochlorothiazide
Drug
Tier
1
2
1
4
2
2
1
1
1
Requirements/Limits
MO GC
PA MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
1
4
1
3
4
MO GC
4
4
QL (30 EA per 30 days)
QL (60 EA per 30 days)
4
1
2
2
4
1
3
1
3
1
2
1
4
1
4
4
1
2
1
MO GC
QL (120 EA per 30 days) PA MO
QL (30 EA per 30 days) ST
MO GC
MO GC
MO GC
QL (30 EA per 30 days) ST
MO GC
QL (30 EA per 30 days) ST MO
MO GC
QL (30 EA per 30 days) ST MO
MO GC
MO
MO GC
QL (60 EA per 30 days)
MO GC
MO GC
QL (60 EA per 30 days) MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 32 of 73
Drug Name
losartan potassium/hydrochlorothiazide
methyldopa/hydrochlorothiazide
metoprolol/hydrochlorothiazide
MICARDIS HCT
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
propranolol/hydrochlorothiazide
quinapril/hydrochlorothiazide
reserpine
SIMCOR
spironolactone/hydrochlorothiazide
TARKA
TEKAMLO
TEKTURNA HCT
triamterene/hydrochlorothiazide
TRIBENZOR
TWYNSTA
valsartan/hydrochlorothiazide
VYTORIN TABS 10MG, 10MG, 10MG, 20MG, 10MG,
40MG
VYTORIN TABS 10MG, 80MG
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide
acetazolamide er
methazolamide
Diuretics, Loop
bumetanide
EDECRIN
furosemide inj, tabs
furosemide oral soln 10mg/ml
torsemide tabs
Diuretics, Potassium-sparing
amiloride hcl
DYRENIUM
eplerenone
spironolactone
Diuretics, Thiazide
chlorothiazide
chlorthalidone tabs 25mg, 50mg
Drug
Tier
1
2
1
4
2
2
1
1
2
4
1
4
4
4
1
3
3
2
4
Requirements/Limits
MO GC
MO GC
MO GC
QL (30 EA per 30 days) ST
MO GC
MO GC
MO GC
MO GC
MO GC
QL (30 EA per 30 days)
MO GC
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
MO GC
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
MO
QL (30 EA per 30 days) ST
4
QL (30 EA per 30 days) ST PA
1
2
1
MO GC
MO GC
MO GC
1
4
1
1
1
MO GC
1
4
2
1
MO GC
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 33 of 73
Drug Name
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
THALITONE
Dyslipidemics, Fibric Acid Derivatives
ANTARA
fenofibrate micronized
fenofibrate tabs 160mg, 54mg
fenofibrate tabs 145mg, 48mg
FENOGLIDE
gemfibrozil
LIPOFEN CAPS 150MG
LOFIBRA TABS 160MG
NALFON
TRILIPIX
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
CRESTOR
fluvastatin caps 20mg
fluvastatin caps 40mg
LESCOL XL
LIVALO
lovastatin
pravastatin sodium
simvastatin tabs 10mg, 20mg, 40mg, 5mg
simvastatin tabs 80mg
Dyslipidemics, Other
cholestyramine light pack
colestipol hcl
LOVAZA
niacor
NIASPAN
prevalite powd
SIMCOR TB24 1000MG, 40MG, 500MG, 40MG
VASCEPA
ZETIA
Vasodilators, Direct-acting Arterial/ Venous
Drug
Tier
1
1
1
1
4
Requirements/Limits
MO GC
MO GC
MO GC
MO GC
3
1
1
2
4
1
3
4
4
4
ST MO
MO GC
MO GC
MO GC
ST
QL (60 EA per 30 days) MO GC
ST MO
ST
ST
2
3
2
2
4
4
1
1
1
1
MO GC
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO GC
QL (60 EA per 30 days) MO GC
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
MO GC
MO GC
MO GC
PA MO GC
1
1
4
1
3
1
3
3
4
MO GC
MO GC
QL (120 EA per 30 days)
MO GC
QL (60 EA per 30 days) MO
MO GC
QL (60 EA per 30 days) MO
MO
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 34 of 73
Drug Name
DILATRATE SR
ISORDIL TITRADOSE
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate er
isosorbide mononitrate tabs 10mg
isosorbide mononitrate tabs 20mg
minitran
NITRO-BID
nitroglycerin
nitroglycerin transdermal
nitrolingual pumpspray
NITROMIST
NITROSTAT
RECTIV
Vasodilators, Direct-acting Arterial
hydralazine hcl tabs
minoxidil
Cardiovascular Drugs
Vasodilating Agents
CIALIS
VIAGRA
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
ADDERALL XR CP24 2.5MG, 2.5MG, 2.5MG, 2.5MG,
3.75MG, 3.75MG, 3.75MG, 3.75MG, 5MG, 5MG, 5MG,
5MG, 6.25MG, 6.25MG, 6.25MG, 6.25MG, 7.5MG, 7.5MG,
7.5MG, 7.5MG
adderall xr cp24 1.25mg, 1.25mg, 1.25mg, 1.25mg
amphetamine/dextroamphetamine tabs
amphetamine/dextroamphetamine cp24
dextroamphetamine sulfate
dextroamphetamine sulfate er
methamphetamine hcl
Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines
DAYTRANA
dexmethylphenidate hcl
FOCALIN XR CP24 10MG, 15MG
Drug
Tier
4
4
1
1
1
1
1
1
3
1
1
2
4
3
3
Requirements/Limits
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO
MO GC
MO GC
MO GC
MO
MO
1
1
MO GC
MO GC
1
1
QL (6 EA per 31 days) MO GC ED
QL (6 EA per 31 days) MO GC ED
4
QL (30 EA per 30 days) PA
2
1
2
1
2
2
QL (30 EA per 30 days) PA MO GC
PA MO GC
QL (30 EA per 30 days) PA MO
PA MO GC
PA MO GC
PA MO GC
4
1
4
QL (30 EA per 30 days) PA
MO GC
QL (30 EA per 30 days) PA
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 35 of 73
Drug Name
FOCALIN XR CP24 20MG
INTUNIV
METADATE CD CPCR 60MG
METADATE CD CPCR 10MG, 20MG
metadate er
methylphenidate hcl
methylphenidate hcl cd cpcr 50mg, 60mg
methylphenidate hcl cd cpcr 10mg
methylphenidate hcl er tbcr 20mg
methylphenidate hydrochloride
STRATTERA
Central Nervous System, Other
NUEDEXTA
RILUTEK
XENAZINE
Fibromyalgia Agents
SAVELLA
SAVELLA TITRATION PACK
Multiple Sclerosis Agents
AMPYRA
AUBAGIO
AVONEX
BETASERON
COPAXONE
EXTAVIA
GILENYA
REBIF
REBIF TITRATION PACK
TYSABRI
Psychotherapeutic Agents
bupropion hcl xl
Dental and Oral Agents
Dental and Oral Agents
cevimeline hcl
chlorhexidine gluconate oral rinse
EVOXAC
minocycline hcl
periogard
Drug
Tier
4
4
4
4
1
1
2
2
1
2
4
Requirements/Limits
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
PA MO GC
PA MO GC
QL (30 EA per 30 days) PA MO GC
QL (60 EA per 30 days) MO GC
PA MO GC
PA MO GC
QL (30 EA per 30 days) PA
3
5
5
QL (60 EA per 30 days) MO
PA
QL (124 EA per 25 days) PA LA
3
3
QL (60 EA per 30 days) MO
QL (55 EA per 28 days) MO
5
5
5
5
5
5
5
5
5
5
QL (60 EA per 30 days) PA LA
QL (30 EA per 30 days) PA
QL (4 EA per 28 days) PA
QL (15 EA per 28 days) PA
QL (30 EA per 30 days) PA
QL (15 EA per 28 days) PA
QL (28 EA per 28 days) PA
QL (6 ML per 28 days) PA
QL (4.2 ML per 28 days) PA
PA LA
1
MO GC
2
1
4
1
1
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 36 of 73
Drug Name
pilocarpine hcl
pilocarpine hydrochloride
triamcinolone in orabase
Dermatological Agents
Dermatological Agents
adapalene
ammonium lactate
amnesteem
AZELEX
betamethasone dipropionate
calcipotriene crea
calcipotriene oint, soln
CARAC
CLARAVIS CAPS 30MG
claravis caps 10mg, 20mg, 40mg
clindamycin/benzoyl peroxide gel 5%, 1%
clotrimazole/betamethasone dipropionate
CONDYLOX GEL
CORTISPORIN
DOVONEX
ELIDEL
erythromycin/benzoyl peroxide
FINACEA
FLUOROPLEX
fluorouracil external soln
fluorouracil crea, inj
imiquimod
laclotion
nystatin/triamcinolone
OXSORALEN ULTRA
PHISOHEX
podofilox
PROTOPIC OINT 0.03%
PROTOPIC OINT 0.1%
REGRANEX
SANTYL
selenium sulfide lotn
SOLARAZE
SORIATANE
Drug
Tier
2
2
2
2
1
2
4
1
2
2
4
5
2
2
1
4
4
4
4
2
4
4
2
2
1
1
1
4
3
1
4
4
5
4
2
4
5
Requirements/Limits
MO GC
MO GC
MO GC
PA MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
QL (100 GM per 30 days)
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO
MO GC
QL (100 GM per 30 days)
QL (60 GM per 30 days)
QL (30 GM per 30 days) PA
MO GC
QL (60 EA per 30 days) PA
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 37 of 73
Drug Name
STELARA
TACLONEX
TAZORAC
VECTICAL
VEREGEN
VOLTAREN
ZONALON
ZYCLARA
Enzyme Replacement/ Modifiers
Enzyme Replacement/ Modifiers
ADAGEN
ALDURAZYME
BUPHENYL
CARBAGLU
CEREZYME
CREON
FABRAZYME
KUVAN
MYOZYME
NAGLAZYME
ORFADIN
PANCREAZE
PERTZYE
ULTRESA
VIOKACE
ZAVESCA
ZENPEP
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
dicyclomine hcl
glycopyrrolate inj
glycopyrrolate tabs
methscopolamine bromide
Gastrointestinal Agents, Other
CHENODAL
diphenoxylate/atropine
loperamide hcl caps
RELISTOR INJ 12MG/0.6ML
Drug
Tier Requirements/Limits
5 PA
4
4
4
4
4
4
4
4
5
5
5
4
3
5
5
5
5
5
4
4
5
4
5
3
MO
1
1
2
2
PA MO GC
MO GC
MO GC
MO GC
5
1
1
4
PA MO GC
MO GC
QL (18 EA per 30 days) PA
PA LA
PA
MO
PA LA
PA
PA
PA LA
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 38 of 73
Drug Name
ursodiol caps
ursodiol tabs
Gastrointestinal Agents
COLYTE-FLAVOR PACKS
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
GOLYTELY
HELIDAC
PREVPAC
PYLERA
trilyte
Histamine2 (H2) Receptor Antagonists
cimetidine
cimetidine hcl soln
famotidine inj, susr
famotidine tabs 20mg, 40mg
nizatidine
ranitidine hcl caps, syrp, tabs
Irritable Bowel Syndrome Agents
AMITIZA
budesonide
LINZESS
LOTRONEX
Laxatives
constulose
enulose
generlac
HALFLYTELY BOWEL PREP/FLAVOR PACKS
KRISTALOSE
lactulose
MOVIPREP
polyethylene glycol 3350 powd
Protectants
CARAFATE SUSP
misoprostol tabs 200mcg
sucralfate
Proton Pump Inhibitors
DEXILANT
Drug
Tier Requirements/Limits
1 MO GC
2 MO GC
4
1
1
1
4
4
4
4
1
MO GC
MO GC
MO GC
QL (56 EA per 30 days)
QL (14 EA per 30 days)
QL (120 EA per 30 days)
MO GC
1
1
1
1
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
4
2
4
3
QL (60 EA per 30 days) ST
MO GC
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA MO
1
1
1
4
4
1
4
1
MO GC
MO GC
MO GC
MO GC
MO GC
4
1
1
MO GC
MO GC
4
QL (30 EA per 30 days) ST
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 39 of 73
Drug Name
lansoprazole
NEXIUM I.V.
NEXIUM CPDR
NEXIUM PACK 10MG, 20MG, 40MG
omeprazole cpdr
pantoprazole sodium tbec
Genitourinary Agents
Antispasmodics, Urinary
DETROL
DETROL LA
ENABLEX
flavoxate hcl
GELNIQUE GEL 10%
oxybutynin chloride
oxybutynin chloride er
OXYTROL
SANCTURA XR
tolterodine tartrate
TOVIAZ
trospium chloride
trospium chloride er
VESICARE
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
AVODART
finasteride tabs 5mg
JALYN
RAPAFLO
tamsulosin hcl
Genitourinary Agents, Other
bethanechol chloride
DEPEN TITRATABS
ELMIRON
potassium citrate
Phosphate Binders
calcium acetate caps
eliphos
FOSRENOL CHEW 1000MG, 500MG
Drug
Tier
2
4
3
3
1
1
Requirements/Limits
QL (30 EA per 30 days) MO GC
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO GC
MO GC
4
4
3
1
4
1
1
4
3
2
4
2
2
4
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
MO GC
QL (30 GM per 30 days)
MO GC
MO GC
QL (8 EA per 28 days)
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO GC
QL (30 EA per 30 days)
MO GC
QL (30 EA per 30 days) MO GC
QL (30 EA per 30 days)
2
4
1
4
3
1
MO GC
QL (30 EA per 30 days)
MO GC
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
MO GC
2
4
4
2
MO GC
1
2
5
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 40 of 73
Drug Name
PHOSLYRA
RENVELA TABS
RENVELA PACK 2.4GM
RENVELA PACK 0.8GM
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/ Mineralocorticoids
a-hydrocort
alclometasone dipropionate
amcinonide
augmented betamethasone dipropionate
betamethasone dipropionate
betamethasone valerate foam
betamethasone valerate crea, lotn, oint
CAPEX
CELESTONE
clobetasol propionate e
clobetasol propionate gel, oint, soln
clobetasol propionate foam, lotn, sham
CORDRAN
CORDRAN TAPE
cortisone acetate
DERMA-SMOOTHE/FS BODY OIL
DESONATE
desonide crea
desonide lotn, oint
DESOWEN
desoximetasone crea, gel
desoximetasone oint 0.05%
desoximetasone oint 0.25%
dexamethasone
dexamethasone intensol
dexamethasone sodium phosphate
diflorasone diacetate
fludrocortisone acetate
fluocinolone acetonide crea, oint, soln
fluocinolone acetonide oil
fluocinonide
fluocinonide-e
fluticasone propionate
Drug
Tier Requirements/Limits
4
4
5 QL (180 EA per 30 days)
5 QL (525 EA per 30 days)
2
1
1
1
1
1
1
4
4
1
1
2
4
4
1
3
4
1
2
4
2
2
2
1
1
1
2
1
1
2
1
1
1
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 41 of 73
Drug
Drug Name
Tier Requirements/Limits
halobetasol propionate
1 MO GC
HALOG
4
hydrocortisone butyrate
2 MO
hydrocortisone valerate
2 MO GC
hydrocortisone lotn, tabs
1 MO GC
hydrocortisone oint
2 MO GC
KENALOG
4
LOCOID LIPOCREAM
4
methylprednisolone
1 MO GC
methylprednisolone acetate
1 MO GC
methylprednisolone dose pack
1 MO GC
methylprednisolone sodiumsuccinate inj 125mg, 40mg
1 MO GC
methylprednisolone sodiumsuccinate inj 1gm
1 MO GC
MILLIPRED
3 MO
mometasone furoate
1 MO GC
ORAPRED ODT
3 MO
PANDEL
4
prednicarbate
1 MO GC
prednisolone sodium phosphate
1 MO GC
prednisone
1 MO GC
prednisone intensol
1 MO GC
procto-pak
1 MO GC
proctozone-hc
1 MO GC
SOLU-CORTEF INJ 100MG
3 MO
SOLU-CORTEF INJ 250MG
4
triamcinolone acetonide
1 MO GC
u-cort
1 MO GC
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
ACTHAR HP
5 PA
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
desmopressin acetate
2 MO GC
GENOTROPIN
5 ST PA
GENOTROPIN MINIQUICK INJ 0.2MG
4 ST PA
GENOTROPIN MINIQUICK INJ 0.4MG, 0.8MG, 1MG
5 ST PA
HUMATROPE
5 ST PA
INCRELEX
5 PA
NORDITROPIN FLEXPRO
5 PA
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 42 of 73
Drug Name
NORDITROPIN NORDIFLEX PEN
novarel
NUTROPIN AQ PEN
OMNITROPE
pregnyl w/diluent benzyl alcohol/nacl
SAIZEN CLICK.EASY
TEV-TROPIN
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex
Hormones/ Modifiers)
Anabolic Steroids
OXANDROLONE TABS 10MG
oxandrolone tabs 2.5mg
Androgens
ANDRODERM
ANDROGEL
ANDROGEL PUMP
ANDROXY
danazol
METHITEST
STRIANT
testosterone cypionate
testosterone enanthate
TESTRED
Estrogens
ALORA PTTW 0.05MG/24HR, 0.075MG/24HR,
0.1MG/24HR
ALORA PTTW 0.025MG/24HR
CENESTIN
DEPO-ESTRADIOL
DIVIGEL
ELESTRIN
ENJUVIA TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG
ENJUVIA TABS 1.25MG
ESTRACE
estradiol valerate
estradiol tabs
estradiol ptwk 0.025mg/24hr, 0.05mg/24hr, 0.06mg/24hr,
0.1mg/24hr, 37.5mcg/24hr
estradiol ptwk 0.075mg/24hr
Drug
Tier
5
2
5
4
2
5
5
Requirements/Limits
PA
PA MO
ST PA
PA
PA MO GC
ST PA
ST PA
5
2
PA
PA MO GC
3
3
3
4
2
3
4
1
1
4
PA MO
PA MO
PA MO
MO GC
MO
QL (60 EA per 30 days) ST PA
PA MO GC
PA MO GC
PA
4
QL (8 EA per 28 days)
4
4
4
4
4
4
4
4
2
1
1
QL (8 EA per 30 days)
PA
MO GC
MO GC
MO GC
2
MO GC
QL (30 EA per 30 days)
QL (60 EA per 30 days)
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 43 of 73
Drug Name
ESTRING
estropipate
EVAMIST
FEMRING
FEMTRACE TABS 0.9MG
FEMTRACE TABS 0.45MG
MENEST
MENOSTAR
PREMARIN CREA
PREMARIN TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG
PREMARIN TABS 1.25MG
VAGIFEM
VIVELLE-DOT PTTW 0.05MG/24HR, 0.1MG/24HR
VIVELLE-DOT PTTW 0.025MG/24HR, 0.0375MG/24HR
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex
Hormones/ Modifiers)
amethia
amethyst
apri
aranelle
aviane
balziva
briellyn
CLIMARA PRO
COMBIPATCH
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
emoquette
enpresse-28
estradiol/norethindrone acetate
FEMHRT LOW DOSE
gianvi
introvale
jinteli
junel 1.5/30
junel 1/20
junel fe 1.5/30
Drug
Tier
4
1
4
4
4
4
4
4
4
4
4
4
4
4
2
2
1
2
1
2
2
4
4
1
1
1
2
1
2
4
1
2
1
1
1
2
Requirements/Limits
PA MO GC
QL (30 EA per 30 days)
PA
QL (4 EA per 28 days)
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (8 EA per 28 days)
QL (8 EA per 30 days)
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
QL (4 EA per 28 days)
QL (8 EA per 28 days)
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 44 of 73
Drug Name
junel fe 1/20
kariva
kelnor 1/35
leena
lessina
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
low-ogestrel
lutera
marlissa
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mononessa
necon 0.5/35-28
necon 1/35
necon 7/7/7
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
orsythia
portia-28
PREFEST
PREMPHASE
PREMPRO
previfem
quasense
reclipsen
sprintec 28
sronyx
tri-legest fe
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vestura
Drug
Tier
1
2
2
2
2
2
2
1
1
1
1
1
1
2
1
2
1
1
2
1
1
2
2
2
4
4
4
1
2
1
1
2
2
1
1
1
1
2
1
Requirements/Limits
MO GC
MO GC
MO GC
MO GC
MO GC
QL (91 EA per 91 days) MO
MO GC
MO GC
MO GC
QL (28 EA per 28 days) MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
QL (30 EA per 30 days) PA
QL (28 EA per 28 days) PA
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 45 of 73
Drug Name
zenchent fe
zeosa
zovia 1/35e
zovia 1/50e
Progestins
camila
CRINONE
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
errin
jolivette
medroxyprogesterone acetate tabs
medroxyprogesterone acetate inj
megestrol acetate
next choice
nora-be
norethindrone acetate
progesterone
Selective Estrogen Receptor Modifying Agents
EVISTA
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
levothroid
levothyroxine sodium
levoxyl
liothyronine sodium
SYNTHROID
TIROSINT
unithroid
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
Drug
Tier
2
2
2
2
Requirements/Limits
MO GC
MO GC
MO GC
MO GC
1
4
4
4
1
1
1
2
1
2
1
2
2
MO GC
3
QL (30 EA per 30 days) MO
1
1
1
1
3
4
1
MO GC
MO GC
MO GC
MO GC
MO
3
MO
3
PA MO
2
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 46 of 73
Drug Name
ELIGARD INJ 22.5MG, 30MG, 7.5MG
ELIGARD INJ 45MG
FIRMAGON INJ 120MG
leuprolide acetate
LUPRON DEPOT-PED INJ 11.25MG, 15MG
LUPRON DEPOT INJ 22.5MG, 3.75MG, 30MG, 45MG,
7.5MG
OCTREOTIDE ACETATE INJ 1000MCG/ML,
200MCG/ML, 500MCG/ML
octreotide acetate inj 100mcg/ml, 50mcg/ml
SANDOSTATIN LAR DEPOT
SOMATULINE DEPOT INJ 120MG/0.5ML, 60MG/0.2ML
SOMAVERT
SYNAREL
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
Hormonal Agents, Suppressant (Sex Hormones/ Modifiers)
Antiandrogens
bicalutamide
flutamide
NILANDRON
ZYTIGA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole
propylthiouracil
Immunological Agents
Immune Suppressants
AFINITOR
AZASAN TABS 75MG
azathioprine
azathioprine sodium
CELLCEPT SUSR
CIMZIA INJ 200MG/ML
cyclosporine modified caps 50mg
cyclosporine modified soln
cyclosporine caps
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
Drug
Tier
4
5
5
2
5
5
Requirements/Limits
PA
PA
PA
MO GC
PA
PA
5
PA
2
5
5
5
4
5
5
PA MO GC
PA
PA
PA LA
PA
PA
PA
1
1
4
5
MO GC
MO GC
1
1
MO GC
MO GC
5
4
1
2
4
5
2
2
2
5
5
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA
MO GC
MO GC
PA
QL (6 EA per 28 days) PA
B/D MO GC
B/D MO GC
B/D MO GC
QL (16 EA per 28 days) PA
QL (200 ML per 28 days) PA
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 47 of 73
Drug Name
ENBREL INJ 25MG/0.5ML
gengraf
HUMIRA
KINERET
mercaptopurine
methotrexate
methotrexate sodium inj 25mg/ml
mycophenolate mofetil
MYFORTIC TBEC 180MG
MYFORTIC TBEC 360MG
ORENCIA
RAPAMUNE SOLN
RAPAMUNE TABS 0.5MG
RAPAMUNE TABS 1MG, 2MG
REMICADE
RHEUMATREX
SIMPONI
TACROLIMUS CAPS 5MG
tacrolimus caps 0.5mg
tacrolimus caps 1mg
TREXALL TABS 10MG, 15MG
XELJANZ
ZORTRESS TABS 0.5MG, 0.75MG
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJ 3GM
GAMASTAN S/D
GAMMAGARD LIQUID
Immunomodulators
ACTEMRA INJ 200MG/10ML
ACTIMMUNE
ARCALYST
leflunomide
RIDAURA
Vaccines
ACTHIB
ADACEL
BOOSTRIX
CERVARIX
Drug
Tier
5
2
5
5
1
1
1
2
4
5
5
5
4
5
5
4
5
5
2
2
4
5
5
5
4
5
5
5
5
1
4
3
3
4
4
Requirements/Limits
QL (600 ML per 90 days) PA
B/D MO GC
QL (6 EA per 28 days) PA
QL (18.8 ML per 28 days) PA
MO GC
MO GC
MO GC
PA MO GC
B/D
B/D
PA
B/D
B/D
B/D
PA
QL (1 ML per 30 days) PA
PA
B/D MO GC
PA MO GC
QL (60 EA per 30 days) PA
PA
B/D
B/D
PA
PA LA
MO GC
MO
MO
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 48 of 73
Drug Name
COMVAX
DAPTACEL
DECAVAC
ENGERIX-B INJ 10MCG/0.5ML, 20MCG/ML
GARDASIL
HAVRIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
M-M-R II W/DILUENT 10 DOSE
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
PEDVAX HIB
PROQUAD
RABAVERT
RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML
ROTATEQ
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT
TWINRIX
TYPHIM VI
VAQTA INJ 25UNIT/0.5ML
VARIVAX
YF-VAX
ZOSTAVAX
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO
ASACOL
ASACOL HD
balsalazide disodium
CANASA
DIPENTUM
LIALDA
mesalamine kit
PENTASA
Glucocorticoids
Drug
Tier
4
4
3
3
4
3
4
4
4
4
4
4
4
4
4
4
4
4
4
3
3
4
4
4
4
4
4
3
4
4
2
4
4
4
2
4
Requirements/Limits
MO
B/D MO
MO
B/D
MO
MO
QL (1 EA per 365 days)
MO
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 49 of 73
Drug Name
colocort
hydrocortisone
proctocream hc
Sulfonamides
sulfasalazine tabs
sulfazine ec
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL TABS 150MG
ACTONEL TABS 30MG, 5MG
ACTONEL TABS 35MG
alendronate sodium
ATELVIA
calcitonin-salmon
calcitriol caps
etidronate disodium tabs 400mg
FORTEO
FORTICAL
FOSAMAX PLUS D
HECTOROL CAPS
ibandronate sodium
PAMIDRONATE DISODIUM INJ 6MG/ML
PROLIA
RECLAST
XGEVA
ZEMPLAR CAPS 1MCG, 2MCG
ZEMPLAR INJ 2MCG/ML
ZOMETA INJ 4MG/5ML
Ophthalmic Agents
Ophthalmic Agents, Other
RESTASIS
Ophthalmic Agents
bacitracin/polymyxin b
BLEPHAMIDE
BLEPHAMIDE S.O.P.
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone
Drug
Tier
2
2
1
Requirements/Limits
MO GC
MO GC
MO GC
1
1
MO GC
MO GC
4
4
4
1
4
2
2
2
5
4
4
4
2
4
4
4
5
4
4
5
QL (1 EA per 28 days) ST
QL (30 EA per 30 days) ST
QL (4 EA per 30 days) ST
MO GC
QL (4 EA per 28 days) ST
MO GC
B/D MO GC
MO GC
QL (2.4 ML per 30 days) PA
QL (4 EA per 28 days) ST
ST B/D
QL (1 EA per 30 days) MO GC
B/D
QL (1 ML per 180 days) PA
B/D
QL (5.1 ML per 90 days) PA
B/D
B/D
B/D
4
1
4
4
1
2
1
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 50 of 73
Drug Name
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hydrocortisone
PRED-G
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium phosphate
TOBRADEX ST
tobramycin/dexamethasone
trimethoprim sulfate/polymyxin b sulfate
ZYLET
Ophthalmic Anti-allergy Agents
ALOCRIL
ALOMIDE
azelastine hcl
BEPREVE
cromolyn sodium
ELESTAT
EMADINE
epinastine hcl
LASTACAFT
PATADAY
PATANOL
Ophthalmic Anti-inflammatories
ACUVAIL
ALREX
BROMDAY
bromfenac
dexamethasone sodium phosphate
diclofenac sodium
DUREZOL
FLAREX
flurbiprofen sodium
FML
FML FORTE
ketorolac tromethamine
LOTEMAX
MAXIDEX
MILLIPRED
NEVANAC
ORAPRED ODT
Drug
Tier
1
2
3
1
1
4
2
1
4
4
4
2
4
1
4
4
2
4
4
4
4
4
3
2
1
1
4
3
1
3
3
1
4
3
4
4
4
Requirements/Limits
MO GC
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
ST
MO GC
MO
MO GC
MO GC
MO GC
MO
MO GC
MO
MO
MO GC
MO
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 51 of 73
Drug Name
PRED MILD
prednisolone acetate
prednisolone sodium phosphate
VEXOL
Ophthalmic Antiglaucoma Agents
ALPHAGAN P SOLN 0.1%
apraclonidine
AZOPT
betaxolol hcl
BETIMOL
BETOPTIC-S
brimonidine tartrate
carteolol hcl
COMBIGAN
dorzolamide hcl
dorzolamide hcl/timolol maleate
ISTALOL
levobunolol hcl soln 0.5%
metipranolol
PHOSPHOLINE IODIDE
PILOPINE HS
timolol maleate
timolol maleate ophthalmic gel forming
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost
LUMIGAN SOLN 0.03%
LUMIGAN SOLN 0.01%
TRAVATAN Z
Otic Agents
Otic Agents
acetasol hc
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
DERMOTIC
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic susp
Drug
Tier
3
1
1
3
4
2
4
2
4
4
1
1
4
1
2
4
1
1
4
4
1
1
Requirements/Limits
MO
MO GC
MO GC
MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
1
3
3
3
MO GC
MO
PA MO
MO
2
4
4
4
4
4
1
1
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 52 of 73
Drug Name
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ALVESCO
ASMANEX 120 METERED DOSES
ASMANEX 30 METERED DOSES AEPB 110MCG/INH
budesonide
FLOVENT DISKUS
FLOVENT HFA
flunisolide soln 0.025%
fluticasone propionate
NASONEX
PULMICORT FLEXHALER
QVAR
RHINOCORT AQUA
triamcinolone acetonide
VERAMYST
Antihistamines
ASTEPRO
azelastine hcl
carbinoxamine maleate
cetirizine hcl syrp
cyproheptadine hcl
desloratadine
desloratadine odt
levocetirizine dihydrochloride tabs
PATANASE
Antileukotrienes
montelukast sodium chew, tabs
SINGULAIR
zafirlukast
ZYFLO CR
Antitussives
hydrocodone bitartrate/homatropine methylbromide
Drug
Tier Requirements/Limits
4
4
4
2
4
4
2
2
3
4
4
4
2
4
B/D MO GC
MO GC
MO GC
MO
ST
MO GC
ST
3
2
1
1
1
2
2
1
4
MO
MO GC
MO GC
MO GC
PA MO GC
MO
MO
MO GC
2
3
2
4
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO GC
QL (120 EA per 30 days)
1
QL (180 ML per 31 days) MO GC
ED
QL (180 ML per 31 days) MO GC
ED
QL (180 ML per 31 days) MO GC
ED
promethazine vc/codeine
1
promethazine/codeine
1
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 53 of 73
Drug Name
promethazine/dextromethorphan
Bronchodilators, Anticholinergic
ATROVENT HFA
ipratropium bromide inhalation soln
ipratropium bromide nasal soln
SPIRIVA HANDIHALER
TUDORZA PRESSAIR
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
aminophylline
ELIXOPHYLLIN
LUFYLLIN
theophylline cr
theophylline er tb24
theophylline er tb12 300mg, 450mg
Bronchodilators, Sympathomimetic
albuterol sulfate er tb12 8mg
albuterol sulfate er tb12 4mg
albuterol sulfate syrp, tabs
albuterol sulfate nebu 0.083%, 0.5%
albuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml
ARCAPTA NEOHALER
BROVANA
DULERA
epinephrine hcl inj 0.1mg/ml
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
FORADIL AEROLIZER
levalbuterol 1.25 MG/0.5ML
MAXAIR AUTOHALER
metaproterenol sulfate syrp
PERFOROMIST
PROAIR HFA
PROVENTIL HFA
SEREVENT DISKUS
terbutaline sulfate
TWINJECT INJ 0.3MG/0.3ML
VENTOLIN HFA
Drug
Tier Requirements/Limits
1 QL (180 ML per 31 days) MO GC
ED
4
1
1
3
4
B/D MO GC
MO GC
MO
QL (60 EA per 30 days)
1
4
4
1
1
1
MO GC
1
2
1
1
2
4
4
4
1
4
4
4
2
4
1
4
4
4
4
1
4
4
MO GC
MO GC
MO GC
B/D MO GC
B/D MO GC
MO GC
MO GC
MO GC
B/D
QL (13 GM per 25 days)
MO GC
QL (2 EA per 30 days)
QL (2 EA per 30 days)
QL (60 EA per 30 days)
B/D MO GC
MO GC
B/D
QL (60 EA per 30 days)
MO GC
QL (4 EA per 30 days)
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 54 of 73
Drug Name
XOPENEX HFA
Mast Cell Stabilizers
cromolyn sodium nebu
Pulmonary Antihypertensives
ADCIRCA
LETAIRIS
REVATIO TABS
SILDENAFIL CITRATE
TRACLEER TABS 62.5MG
TRACLEER TABS 125MG
VENTAVIS SOLN 10MCG/ML
Respiratory Tract Agents, Other
acetylcysteine soln
ARALAST NP INJ 400MG
KALYDECO
PROLASTIN-C
TYZINE
TYZINE PEDIATRIC NASAL DROPS
ZEMAIRA
Respiratory Tract Agents
ADVAIR DISKUS
ADVAIR HFA
COMBIVENT
COMBIVENT RESPIMAT
DALIRESP
ipratropium bromide/albuterol sulfate
promethazine vc
PULMOZYME
SYMBICORT
XOLAIR
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
carisoprodol tabs 350mg
chlorzoxazone
cyclobenzaprine hcl er
cyclobenzaprine hcl tabs 10mg, 5mg
LORZONE
methocarbamol
orphenadrine citrate
Drug
Tier Requirements/Limits
4
2
B/D MO GC
5
5
5
5
5
5
5
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA LA
QL (90 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
PA
2
5
5
5
3
3
5
B/D MO GC
PA LA
PA
PA LA
MO
MO
PA LA
4
4
4
4
4
2
1
5
3
5
QL (60 EA per 30 days)
QL (60 GM per 30 days)
B/D MO GC
PA MO GC
PA
QL (11 GM per 30 days) MO
PA LA
2
2
2
2
3
2
2
PA MO GC
PA MO GC
PA MO GC
PA MO GC
PA MO
PA MO GC
PA MO GC
QL (8 GM per 30 days)
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 55 of 73
Drug Name
orphenadrine citrate er
soma tabs 250mg
tizanidine hcl
Sleep Disorder Agents
GABA Receptor Modulators
LUNESTA
zaleplon
zolpidem tartrate
zolpidem tartrate er
Sleep Disorders, Other
modafinil
NUVIGIL
ROZEREM
XYREM
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/ Mineral Modifiers
EXJADE
kionex
SAMSCA
Electrolyte/ Mineral Replacement
klor-con 10
klor-con 8
KLOR-CON M15
klor-con m20
OSMOPREP
PLASMA-LYTE-148
potassium chloride
potassium chloride 0.15% /nacl 0.45% viaflex
potassium chloride 0.15% nacl 0.9%
potassium chloride er
sodium chloride
sodium chloride 0.45% viaflex
sodium chloride 0.9%
SUPREP BOWEL PREP
Therapeutic Nutrients/ Minerals/ Electrolytes
AMINOSYN II
AMINOSYN M
AMINOSYN-HBC
Drug
Tier
2
2
2
Requirements/Limits
PA MO GC
MO GC
MO GC
4
1
1
2
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) MO GC
QL (30 EA per 30 days) MO GC
QL (30 EA per 30 days) MO GC
2
4
4
5
PA MO
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) ST
QL (540 ML per 30 days) PA LA
5
2
5
PA LA
MO GC
PA
1
1
3
1
4
4
1
1
1
1
1
1
1
4
MO GC
MO GC
MO
MO GC
3
3
3
B/D MO
B/D MO
B/D MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 56 of 73
Drug Name
AMINOSYN-PF
AMINOSYN-PF 7%
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
CLINISOL SF 15%
dextrose 10% flex container
dextrose 10%/nacl 0.2%
dextrose 2.5%/sodium chloride 0.45%
dextrose 5%
DEXTROSE 5%/LACTATED RINGERS
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
FREAMINE III 3%
HEPATASOL
intralipid
IONOSOL-B/DEXTROSE 5%
ISOLYTE-P/DEXTROSE 5%
kcl 0.075%/d5w/nacl 0.45%
KCL 0.15%/D5W/LR
kcl 0.15%/d5w/nacl 0.2%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
1
1
1
1
4
1
1
1
1
1
3
3
1
4
4
1
4
1
1
1
4
Requirements/Limits
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D MO
B/D
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
B/D MO
B/D MO
B/D MO GC
MO GC
MO GC
MO GC
MO GC
PA = Prior Authorization. ST = Step Therapy. QL = Quantity Limit. GC = Gap Coverage: We may provide coverage
for this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about
this coverage. GCD= Additional Gap Coverage for specific plans. LA = Limited Availability: This prescription may
be available only at certain pharmacies. For more information 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 available through mail-order service, please refer to our Evidence of
Coverage for more information. ED = Excluded Drug: This prescription 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 for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Page 57 of 73
Drug Name
lactated ringers irrigation
lactated ringers viaflex
levocarnitine
NEPHRAMINE
normosol-m in d5w
normosol-r in d5w
PLASMA-LYTE-56/D5W
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45% viaflex
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride 0.224%/dextrose 5% viaflex
potassium chloride 0.3%/d5w
PREMASOL
PROCALAMINE
PROSOL
sterile water irrigation
TRAVASOL
Vitamins
Vitamin B Complex
folic acid
Vitamin D
ergocalciferol
Drug
Tier
2
2
2
3
1
1
4
1
1
1
1
1
3
3
3
1
4
Requirements/Limits
MO GC
MO GC
B/D MO GC
B/D MO
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
MO GC
B/D MO
B/D MO
B/D MO
MO GC
B/D
1
MO GC ED
1
QL (4 EA per 31 days) MO GC ED
PA=Autorización previa. ST=Terapia por fases. QL=Límite en la Cantidad. GC=Es posible que proporcionemos
cobertura adicional de este medicamento recetado durante la brecha en la cobertura. Consulte nuestra Evidencia de
Cobertura para obtener más información sobre esta cobertura. GCD= Cobertura adicional durante la brecha para
cierto planes. 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 con TTY/TDD deben marcar 711. MO=Este medicamento recetado puede obtener mediante pedido por
correo. ED=Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de
Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su
costo total de medicamentos (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
ayuda adicional para pagar este medicamento.
Page 58 of 73
Index
A
abacavir.....................................22
abelcet.......................................14
abilify discmelt tbdp 10mg .......21
abilify discmelt tbdp 15mg .......21
abilify inj ..................................21
abilify oral soln.........................21
abilify tabs 10mg, 15mg, 2mg, 5mg
..............................................21
abilify tabs 20mg, 30mg ...........21
abstral subl 100mcg ....................3
abstral subl 200mcg, 800mcg .....3
acarbose ....................................25
acebutolol hcl............................31
acetaminophen/caffeine/dihydrocodeine
bitartrate .................................1
acetaminophen/codeine #3 .........1
acetaminophen/codeine soln.......1
acetaminophen/codeine tabs 300mg,
15mg.......................................1
acetaminophen/codeine tabs 300mg,
60mg.......................................1
acetasol hc ................................52
acetazolamide ...........................33
acetazolamide er .......................33
acetic acid ...................................5
acetylcysteine soln....................55
actemra inj 200mg/10ml ...........48
acthar hp ...................................42
acthib ........................................48
actimmune ................................48
actonel tabs 150mg ...................50
actonel tabs 30mg, 5mg ............50
actonel tabs 35mg .....................50
actoplus met..............................27
actoplus met xr..........................27
actos..........................................25
acuvail.......................................51
acyclovir ...................................24
acyclovir sodium inj 500mg .....24
aczone .......................................16
adacel........................................48
adagen.......................................38
adapalene ..................................37
adcirca.......................................55
adderall xr cp24 1.25mg, 1.25mg,
1.25mg, 1.25mg....................35
adderall xr cp24 2.5mg, 2.5mg, 2.5mg,
2.5mg, 3.75mg, 3.75mg, 3.75mg,
3.75mg, 5mg, 5mg, 5mg, 5mg,
6.25mg, 6.25mg, 6.25mg, 6.25mg,
7.5mg, 7.5mg, 7.5mg, 7.5mg35
adriamycin inj 2mg/ml..............17
advair diskus .............................55
advair hfa ..................................55
advicor tb24 20mg, 1000mg, 20mg,
500mg, 20mg, 750mg...........32
advicor tb24 40mg, 1000mg.....32
afeditab cr .................................31
afinitor ................................18, 47
afinitor tabs 10mg.....................18
afinitor tabs 5mg.......................18
afinitor tabs 7.5mg....................18
aggrenox ...................................29
a-hydrocort ...............................41
akne-mycin .................................8
albenza......................................19
albuterol sulfate er tb12 4mg ....54
albuterol sulfate er tb12 8mg ....54
albuterol sulfate nebu 0.083%, 0.5%
..............................................54
albuterol sulfate nebu 0.63mg/3ml,
1.25mg/3ml ..........................54
albuterol sulfate syrp, tabs ........54
alclometasone dipropionate ......41
Alcohol Deterrents/ Anti-craving4
alcohol preps pads ......................5
aldactazide ................................32
aldurazyme ...............................38
alendronate sodium...................50
alfuzosin hcl er..........................40
alimta ........................................17
alinia tabs..................................19
Alkylating Agents.....................16
allopurinol.................................15
alocril........................................51
alomide .....................................51
alora pttw 0.025mg/24hr...........43
alora pttw 0.05mg/24hr, 0.075mg/24hr,
0.1mg/24hr ...........................43
aloxi ..........................................13
Alpha-adrenergic Agonists .......29
Alpha-adrenergic Blocking Agents
..............................................29
alphagan p soln 0.1%................52
alprazolam er tb24 0.5mg .........24
alprazolam intensol...................24
alprazolam odt tbdp 0.25mg, 0.5mg
..............................................24
alprazolam odt tbdp 1mg, 2mg .25
alprazolam tabs 0.25mg, 0.5mg 25
alprazolam tabs 1mg, 2mg........25
alprazolam xr tb24 1mg, 2mg, 3mg
..............................................25
alrex ..........................................51
altabax.........................................5
alvesco ......................................53
amantadine hcl..........................20
ambisome..................................14
amcinonide ...............................41
amethia .....................................44
amethyst....................................44
amifostine .................................17
amikacin sulfate inj 1gm/4ml .....5
amiloride hcl.............................33
amiloride/hydrochlorothiazide..32
Aminoglycosides ........................5
aminophylline ...........................54
Aminosalicylates ......................49
aminosyn ii ...............................56
aminosyn m ..............................56
aminosyn-hbc ...........................56
aminosyn-pf ..............................57
aminosyn-pf 7%........................57
amiodarone hcl tabs 400mg......30
amitiza ......................................39
amitriptyline hcl........................13
amlodipine besylate ............31, 32
amlodipine besylate/benazepril hcl
..............................................32
amlodipine besylate/benazepril
hydrochloride .......................32
ammonium lactate ....................37
amnesteem ................................37
amoxapine tabs 100mg, 25mg, 50mg
..............................................13
amoxicillin caps, susr, tabs .........7
amoxicillin chew 250mg ............7
amoxicillin/clavulanate potassium chew
................................................7
amoxicillin/clavulanate potassium er
................................................7
amoxicillin/clavulanate potassium susr
250mg/5ml, 62.5mg/5ml,
400mg/5ml, 57mg/5ml, 600mg/5ml,
42.9mg/5ml ............................7
amoxicillin/clavulanate potassium tabs
250mg, 125mg........................7
amoxicillin/potassium clavulanate susr
200mg/5ml, 28.5mg/5ml ........7
amoxicillin/potassium clavulanate tabs
................................................7
amphetamine/dextroamphetamine cp24
..............................................35
amphetamine/dextroamphetamine tabs
..............................................35
amphotec inj 50mg ...................14
amphotericin b ..........................14
ampicillin caps............................7
ampicillin sodium inj 125mg, 1gm
................................................7
59
ampicillin-sulbactam inj 10gm, 5gm,
2gm, 1gm................................7
ampyra ......................................36
amturnide..................................32
Anabolic Steroids .....................43
anagrelide hydrochloride ..........29
Analgesics...........................1, 3, 4
anastrozole................................18
ancobon.....................................14
androderm.................................43
androgel ....................................43
androgel pump ..........................43
Androgens.................................43
androxy .....................................43
Anesthetics .................................4
Angiotensin II Receptor Antagonists
..............................................30
Angiotensin-converting Enzyme (ACE)
Inhibitors ..............................30
antara ........................................34
Anthelmintics............................19
Anti-Addiction/ Substance Abuse
Treatment Agents ...................4
Antiandrogens...........................47
Antiangiogenic Agents .............17
Antiarrhythmics ........................30
Antibacterials..........................5, 6
Antibacterials, Other...................5
Anticholinergics........................20
Anticoagulants ..........................28
Anticonvulsants ..........................9
Anticonvulsants, Other ...............9
Anti-cytomegalovirus (CMV) Agents
..............................................22
Antidementia Agents ................11
Antidementia Agents, Other .....11
Antidepressants...................11, 12
Antidepressants, Other..............11
Antidiabetic Agents ..................25
Antiemetics...............................13
Antiemetics, Other....................13
Antiestrogens/Modifiers ...........17
Antifungals ...............................14
Antigout Agents........................15
Antihepatitis Agents .................23
Antiherpetic Agents..................24
Antihistamines ..........................53
Anti-HIV Agents, Non-nucleoside
Reverse Transcriptase Inhibitors
..............................................22
Anti-HIV Agents, Nucleoside and
Nucleotide Reverse Transcriptase
Inhibitors ..............................22
Anti-HIV Agents, Other ...........23
Anti-HIV Agents, Protease Inhibitors
..............................................23
Anti-inflammatories, Inhaled
Corticosteroids .....................53
Anti-inflammatory Agents..........5
Anti-influenza Agents...............23
Antileukotrienes........................53
Antimetabolites.........................17
Antimigraine Agents.................15
Antimyasthenic Agents.............16
Antimycobacterials...................16
Antimycobacterials, Other........16
Antineoplastics ...................16, 17
Antineoplastics, Other ..............17
Antiparasitics ............................19
Antiparkinson Agents ...............20
Antiparkinson Agents, Other....20
Antiprotozoals ..........................19
Antipsychotics ..........................20
Antispasmodics, Gastrointestinal38
Antispasmodics, Urinary ..........40
Antispasticity Agents................22
Antithyroid Agents ...................47
Antituberculars .........................16
Antitussives ..............................53
Antivirals ............................22, 24
Anxiolytics ...............................24
Anxiolytics, Other ....................24
apidra ........................................27
apidra solostar...........................27
aplenzin.....................................11
apokyn ......................................20
apraclonidine ............................52
apri............................................44
apriso ........................................49
aptivus caps ..............................23
aptivus soln...............................23
aralast np inj 400mg .................55
aranelle .....................................44
aranesp albumin free inj 100mcg/ml
..............................................29
aranesp albumin free inj 200mcg/ml
..............................................29
aranesp albumin free inj 25mcg/ml
..............................................29
aranesp albumin free inj 300mcg/0.6ml
..............................................29
aranesp albumin free inj 40mcg/ml
..............................................29
aranesp albumin free inj 500mcg/ml
..............................................29
aranesp albumin free inj 60mcg/ml
..............................................29
arcalyst......................................48
arcapta neohaler........................54
Aromatase Inhibitors, 3rd Generation
..............................................18
arranon......................................17
arthrotec 50.................................1
arthrotec 75.................................1
arzerra inj 100mg/5ml ..............19
asacol ........................................49
asacol hd ...................................49
ascomp/codeine ..........................1
asmanex 120 metered doses .....53
asmanex 30 metered doses aepb
110mcg/inh...........................53
astepro.......................................53
astramorph ..................................3
atelvia .......................................50
atenolol ...............................31, 32
atenolol/chlorthalidone .............32
atorvastatin calcium..................34
atovaquone/proguanil hcl tabs 250mg,
100mg...................................19
atripla........................................24
atrovent hfa...............................54
Attention Deficit Hyperactivity
Disorder Agents, Amphetamines
..............................................35
Attention Deficit Hyperactivity
Disorder Agents, Non-amphetamines
..............................................35
aubagio .....................................36
augmented betamethasone dipropionate
..............................................41
avandamet.................................27
avandaryl ..................................27
avandia tabs 2mg, 4mg .............25
avandia tabs 8mg ......................25
avastin.......................................17
avelox .........................................8
aviane........................................44
avodart ......................................40
avonex.......................................36
axert tabs 12.5mg......................16
azasan tabs 75mg......................47
azasite .........................................8
azathioprine ..............................47
azathioprine sodium..................47
azelastine hcl ......................51, 53
azelex........................................37
azilect........................................20
azithromycin inj 500mg..............8
azithromycin susr, tabs ...............8
azopt .........................................52
azor ...........................................32
aztreonam inj 1gm ......................7
B
bacitracin oint .............................5
60
bacitracin/polymyxin b .............50
baclofen ....................................22
bactroban crea.............................5
bactroban nasal ...........................5
balsalazide disodium.................49
balziva.......................................44
banzel susp................................10
banzel tabs 200mg ....................10
banzel tabs 400mg ....................10
baraclude soln...........................24
baraclude tabs 0.5mg ................24
baraclude tabs 1mg ...................24
bd insulin syringe safetyglide/1ml/29g
x 1/2......................................27
bd insulin syringe ultrafine/0.3ml/31g x
5/16.......................................27
bd insulin syringe ultrafine/0.5ml/30g x
1/2.........................................27
bd insulin syringe ultrafine/1ml/31g x
5/16.......................................27
bd pen needle/ultrafine/29g x 12.7mm
..............................................27
benazepril hcl......................30, 32
benazepril hcl/hydrochlorothiazide
..............................................32
benicar ................................30, 32
benicar hct ................................32
Benign Prostatic Hypertrophy Agents
..............................................40
benztropine mesylate ................20
bepreve .....................................51
besivance ....................................8
Beta-adrenergic Blocking Agents31
Beta-lactam, Cephalosporins ......6
Beta-lactam, Other......................7
Beta-lactam, Penicillins ..............7
betamethasone dipropionate37, 41
betamethasone valerate crea, lotn, oint
..............................................41
betamethasone valerate foam....41
betaseron...................................36
betaxolol hcl .......................31, 52
betaxolol hcl tabs 10mg............31
betaxolol hcl tabs 20mg............31
bethanechol chloride.................40
betimol ......................................52
betoptic-s ..................................52
bicalutamide..............................47
bicillin c-r inj 300000unit/ml,
300000unit/ml ........................7
bicillin l-a....................................7
biltricide....................................19
Bipolar Agents..........................25
bisoprolol fumarate.............31, 32
bisoprolol
fumarate/hydrochlorothiazide32
blephamide ...............................50
blephamide s.o.p.......................50
Blood Formation Modifiers ......28
Blood Glucose Regulators ..25, 27
Blood Products/ Modifiers/ Volume
Expanders.......................28, 29
boostrix .....................................48
bosulif .......................................18
botox inj 100unit.......................16
briellyn......................................44
brimonidine tartrate ..................52
bromday....................................51
bromfenac .................................51
bromocriptine mesylate ............20
Bronchodilators, Anticholinergic54
Bronchodilators, Phosphodiesterase
Inhibitors (Xanthines) ..........54
Bronchodilators, Sympathomimetic
..............................................54
brovana .....................................54
budeprion sr ..............................11
budesonide..........................39, 53
bumetanide ...............................33
buphenyl ...................................38
buprenorphine hcl .......................4
buproban ...................................11
bupropion hcl......................11, 36
bupropion hcl sr tb12 200mg....11
bupropion hcl xl........................36
buspirone hcl tabs 10mg, 15mg, 30mg,
5mg.......................................25
buspirone hcl tabs 7.5mg ..........25
butalbital/acetaminophen/caffeine/codei
ne ............................................1
butorphanol tartrate inj 2mg/ml ..4
butorphanol tartrate nasal soln....4
butrans ptwk 10mcg/hr, 20mcg/hr1
butrans ptwk 5mcg/hr .................1
bydureon ...................................26
byetta inj 10mcg/0.04ml ...........26
byetta inj 5mcg/0.02ml .............26
bystolic tabs 10mg ....................31
bystolic tabs 2.5mg ...................31
bystolic tabs 20mg ....................31
bystolic tabs 5mg ......................31
C
cabergoline ...............................46
calcipotriene crea......................37
calcipotriene oint, soln..............37
calcitonin-salmon......................50
calcitriol caps............................50
calcium acetate caps .................40
Calcium Channel Blocking Agents
..............................................31
Calcium Channel Modifying Agents
................................................9
camila .......................................46
campath.....................................17
campral .......................................4
canasa .......................................49
cancidas inj 70mg .....................14
candesartan
cilexetil/hydrochlorothiazide32
capex.........................................41
caprelsa tabs 100mg..................18
caprelsa tabs 300mg..................19
captopril..............................30, 32
captopril/hydrochlorothiazide...32
carac..........................................37
carafate susp .............................39
carbaglu ....................................38
carbamazepine chew, susp........10
carbamazepine er ................10, 25
carbidopa/levodopa...................20
carbidopa/levodopa er...............20
carbinoxamine maleate.............53
carboplatin inj 150mg/15ml......17
Cardiovascular Agents........29, 32
Cardiovascular Agents, Other...32
Cardiovascular Drugs ...............35
carimune nanofiltered inj 3gm..48
carisoprodol tabs 350mg...........55
carisoprodol/aspirin ....................1
carisoprodol/aspirin/codeine.......1
carteolol hcl ..............................52
cartia xt .....................................31
carvedilol ..................................31
cayston........................................7
ceenu.........................................16
cefaclor caps ...............................6
cefadroxil....................................6
cefazolin sodium inj 10gm, 1gm,
500mg.....................................6
cefdinir........................................6
cefepime inj 1gm, 2gm ...............6
cefotaxime sodium inj 10gm, 1gm, 2gm
................................................6
cefotetan .....................................6
cefoxitin sodium inj 1gm, 4%, 2gm
................................................6
cefpodoxime proxetil..................6
cefprozil......................................7
ceftazidime inj 1gm, 2gm ...........7
ceftriaxone sodium inj 10gm, 250mg,
500mg.....................................7
cefuroxime axetil tabs.................7
cefuroxime sodium inj 1.5gm, 7.5gm,
750mg.....................................7
61
celebrex caps 100mg ..................2
celebrex caps 200mg, 400mg, 50mg
................................................2
celestone ...................................41
cellcept susr ..............................47
celontin .......................................9
cenestin .....................................43
Central Nervous System Agents35
Central Nervous System, Other 36
cephalexin caps, susr ..................7
cerezyme...................................38
cervarix .....................................48
cetirizine hcl syrp......................53
cevimeline hcl...........................36
chantix starting month pak .........5
chantix tabs 0.5mg......................5
chantix tabs 1mg.........................5
chenodal....................................38
chlordiazepoxide/amitriptyline.12
chlorhexidine gluconate oral rinse36
chloroquine phosphate..............19
chlorothiazide ...........................33
chlorpromazine hcl ...................13
chlorpropamide tabs 100mg .....26
chlorpropamide tabs 250mg .....26
chlorthalidone tabs 25mg, 50mg33
chlorzoxazone...........................55
cholestyramine light pack.........34
Cholinesterase Inhibitors ..........11
cialis..........................................35
ciclopirox..................................14
ciclopirox nail lacquer ..............14
ciclopirox olamine ....................14
cidofovir ...................................22
cilostazol...................................29
ciloxan oint .................................8
cimetidine .................................39
cimetidine hcl soln....................39
cimzia inj 200mg/ml .................47
cinryze ......................................29
cipro hc .....................................52
cipro susr 500mg/5ml .................8
ciprodex ....................................52
ciprofloxacin er...........................8
ciprofloxacin hcl .........................8
ciprofloxacin inj 400mg/40ml ....8
citalopram hydrobromide .........12
claravis caps 10mg, 20mg, 40mg37
claravis caps 30mg....................37
clarithromycin.............................8
clarithromycin er.........................8
cleocin pediatric granules ...........5
cleocin supp ................................5
climara pro................................44
clindamycin hcl caps 150mg, 300mg
................................................5
clindamycin phosphate add-vantage
................................................5
clindamycin phosphate crea, gel, lotn,
soln, swab...............................5
clindamycin phosphate foam ......5
clindamycin/benzoyl peroxide gel 5%,
1% ........................................37
clinimix 2.75%/dextrose 5%.....57
clinimix 4.25%/dextrose 10%...57
clinimix 4.25%/dextrose 20%...57
clinimix 4.25%/dextrose 25%...57
clinimix 4.25%/dextrose 5%.....57
clinimix 5%/dextrose 15%........57
clinimix 5%/dextrose 20%........57
clinimix 5%/dextrose 25%........57
clinimix e 2.75%/dextrose 10% 57
clinimix e 2.75%/dextrose 5%..57
clinimix e 4.25%/dextrose 25% 57
clinimix e 4.25%/dextrose 5%..57
clinimix e 5%/dextrose 15%.....57
clinimix e 5%/dextrose 20%.....57
clinimix e 5%/dextrose 25%.....57
clinisol sf 15% ..........................57
clobetasol propionate e .............41
clobetasol propionate foam, lotn, sham
..............................................41
clobetasol propionate gel, oint, soln
..............................................41
clomipramine hcl ......................13
clonazepam odt tbdp 0.125mg, 0.25mg,
0.5mg, 1mg...........................25
clonazepam odt tbdp 2mg.........25
clonazepam tabs 0.5mg, 1mg ...25
clonazepam tabs 2mg................25
clonidine hcl ptwk ....................29
clonidine hcl tabs ......................29
clopidogrel tabs 300mg ............29
clopidogrel tabs 75mg ..............29
clorazepate dipotassium............25
clorpres .....................................32
clotrimazole soln, troc ..............14
clotrimazole/betamethasone
dipropionate..........................37
clozapine...................................22
Coagulants ................................29
codeine sulfate tabs 30mg...........4
codeine sulfate tabs 60mg...........4
co-gesic.......................................1
colcrys.......................................15
colestipol hcl.............................34
colistimethate sodium .................6
colocort .....................................50
coly-mycin s .............................52
colyte-flavor packs ...................39
combigan ..................................52
combipatch ...............................44
combivent .................................55
combivent respimat ..................55
cometriq....................................17
complera ...................................22
compro......................................13
comtan ......................................20
comvax .....................................49
condylox gel .............................37
constulose .................................39
copaxone...................................36
cordran......................................41
cordran tape ..............................41
coreg cr .....................................31
cortisone acetate .......................41
cortisporin...........................37, 52
cortisporin-tc.............................52
coumadin ..................................28
creon .........................................38
crestor .......................................34
crinone ......................................46
crixivan caps 400mg.................23
cromolyn sodium ................51, 55
cromolyn sodium nebu .............55
cryselle-28 ................................44
cubicin ........................................6
curity gauze pads 2 ...................27
cyclafem 1/35 ...........................44
cyclafem 7/7/7 ..........................44
cyclobenzaprine hcl er ..............55
cyclobenzaprine hcl tabs 10mg, 5mg
..............................................55
cyclophosphamide tabs.............16
cycloset .....................................26
cyclosporine caps......................47
cyclosporine modified caps 50mg47
cyclosporine modified soln.......47
cymbalta cpep 20mg, 30mg......12
cymbalta cpep 60mg.................12
cyproheptadine hcl....................53
cytarabine aqueous ...................17
D
dacogen.....................................17
daliresp .....................................55
danazol......................................43
dantrolene sodium caps ............22
dapsone .....................................16
daptacel.....................................49
daraprim....................................19
daytrana ....................................35
decavac .....................................49
demeclocycline hcl .....................9
denavir ......................................24
62
Dental and Oral Agents ............36
depen titratabs...........................40
depo-estradiol ...........................43
depo-provera.............................46
depo-subq provera 104 .............46
derma-smoothe/fs body oil .......41
Dermatological Agents .............37
dermotic....................................52
desipramine hcl.........................13
desloratadine.............................53
desloratadine odt.......................53
desmopressin acetate ................42
desonate ....................................41
desonide crea ............................41
desonide lotn, oint.....................41
desowen ....................................41
desoximetasone crea, gel ..........41
desoximetasone oint 0.05% ......41
desoximetasone oint 0.25% ......41
detrol.........................................40
detrol la.....................................40
dexamethasone....................41, 51
dexamethasone intensol............41
dexamethasone sodium phosphate41,
51
dexilant .....................................39
dexmethylphenidate hcl............35
dexrazoxane inj 500mg.............17
dextroamphetamine sulfate.......35
dextroamphetamine sulfate er...35
dextrose 10% flex container .....57
dextrose 10%/nacl 0.2% ...........57
dextrose 2.5%/sodium chloride 0.45%
..............................................57
dextrose 5% ..............................57
dextrose 5%/lactated ringers.....57
dextrose 5%/nacl 0.2% .............57
dextrose 5%/nacl 0.33% ...........57
dextrose 5%/nacl 0.45% ...........57
dextrose 5%/nacl 0.9% .............57
dextrose 5%/potassium chloride 0.15%
..............................................57
diazepam gel .............................25
diazepam soln ...........................25
diazepam tabs 10mg .................25
diazepam tabs 2mg, 5mg ..........25
dibenzyline ...............................29
diclofenac potassium ..................2
diclofenac sodium.................2, 51
diclofenac sodium dr ..................2
diclofenac sodium er...................2
diclofenac sodium/misoprostol...2
dicloxacillin sodium ...................7
dicyclomine hcl.........................38
didanosine.................................22
dificid..........................................8
diflorasone diacetate .................41
diflunisal .....................................2
digoxin soln, tabs......................32
dihydroergotamine mesylate.....15
dilantin................................10, 11
dilantin infatabs ........................11
dilatrate sr .................................35
dilaudid-5....................................4
dilt-cd cp24 120mg, 300mg......31
diltiazem cd cp24 120mg, 240mg,
300mg...................................31
diltiazem hcl er cp12.................31
diltiazem hcl er cp24 180mg, 360mg
..............................................31
diltiazem hcl tabs ......................31
dilt-xr cp24 180mg, 240mg ......31
diovan .......................................30
dipentum ...................................49
diphenhydramine hcl caps 50mg13
diphenoxylate/atropine .............38
dipyridamole.............................29
disopyramide phosphate ...........30
disulfiram....................................4
Diuretics, Carbonic Anhydrase
Inhibitors ..............................33
Diuretics, Loop .........................33
Diuretics, Potassium-sparing ....33
Diuretics, Thiazide....................33
divalproex sodium ....................10
divalproex sodium dr ................10
divalproex sodium er ................10
divigel .......................................43
docetaxel inj 80mg/8ml ............17
donepezil hcl.............................11
Dopamine Agonists ..................20
Dopamine Precursors/ L-Amino Acid
Decarboxylase Inhibitors......20
doribax inj 500mg.......................7
dorzolamide hcl ........................52
dorzolamide hcl/timolol maleate52
dovonex ....................................37
doxazosin mesylate...................29
doxepin hcl ...............................13
doxil..........................................18
doxycycline caps 75mg ..............9
doxycycline hyclate caps ............9
doxycycline hyclate inj...............9
doxycycline hyclate tabs 100mg.9
doxycycline hyclate tabs 20mg...9
doxycycline hyclate tbec 150mg 9
doxycycline monohydrate tabs 150mg,
50mg.......................................9
dronabinol caps 10mg...............13
dronabinol caps 2.5mg, 5mg.....14
droxia caps 300mg....................17
dulera ........................................54
durezol ......................................51
dynacirc cr tb24 10mg ..............31
dynacirc cr tb24 5mg ................31
dyrenium...................................33
Dyslipidemics, Fibric Acid Derivatives
..............................................34
Dyslipidemics, HMG CoA Reductase
Inhibitors ..............................34
Dyslipidemics, Other ................34
E
e.e.s. 400 .....................................8
e.e.s. granules .............................8
econazole nitrate.......................14
edarbi ........................................30
edecrin ......................................33
edurant ......................................22
effient tabs 10mg ......................29
effient tabs 5mg ........................29
Electrolyte/ Mineral Modifiers .56
Electrolyte/ Mineral Replacement56
elestat........................................51
elestrin ......................................43
elidel .........................................37
eligard inj 22.5mg, 30mg, 7.5mg47
eligard inj 45mg........................47
eliphos.......................................40
elixophyllin...............................54
elmiron......................................40
eloxatin inj 100mg/20ml...........18
emadine.....................................51
emcyt ........................................17
emend caps 0 ............................14
emend caps 125mg, 40mg ........14
emend caps 80mg .....................14
Emetogenic Therapy Adjuncts .13
emoquette .................................44
emsam pt24 12mg/24hr ............12
emsam pt24 6mg/24hr, 9mg/24hr12
emtriva......................................22
enablex......................................40
enalapril maleate.................30, 32
enalapril maleate/hydrochlorothiazide
..............................................32
enbrel inj 25mg...................47, 48
enbrel inj 25mg/0.5ml...............48
enbrel inj 50mg/ml ...................47
endocet tabs 325mg, 10mg, 325mg,
7.5mg......................................1
endocet tabs 325mg, 5mg ...........1
endocet tabs 500mg, 7.5mg ........1
endocet tabs 650mg, 10mg .........1
endodan.......................................1
63
engerix-b inj 10mcg/0.5ml, 20mcg/ml
..............................................49
enjuvia tabs 0.3mg, 0.45mg, 0.625mg,
0.9mg....................................43
enjuvia tabs 1.25mg..................43
enoxaparin sodium inj 100mg/ml,
120mg/0.8ml, 150mg/ml ......28
enoxaparin sodium inj 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml .....28
enoxaparin sodium inj 80mg/0.8ml
..............................................28
enpresse-28 ...............................44
enulose......................................39
Enzyme Inhibitors.....................18
Enzyme Replacement/ Modifiers38
epinastine hcl ............................51
epinephrine hcl inj 0.1mg/ml....54
epipen 2-pak .............................54
epipen-jr 2-pak..........................54
epitol .........................................11
epivir hbv..................................24
epivir soln .................................22
eplerenone.................................33
eprosartan mesylate ..................30
epzicom.....................................22
equetro cp12 100mg, 300mg ....11
equetro cp12 200mg .................11
erbitux.......................................18
ergocalciferol ............................58
ergoloid mesylates ....................11
Ergot Alkaloids.........................15
erivedge ....................................18
errin...........................................46
ertaczo.......................................14
ery ...............................................8
eryped 200 ..................................8
eryped 400 ..................................8
ery-tab.........................................8
erythrocin stearate.......................8
erythromycin ethylsuccinate.......8
erythromycin gel, oint, soln........8
erythromycin/benzoyl peroxide 37
escitalopram oxalate soln..........12
escitalopram oxalate tabs 10mg12
escitalopram oxalate tabs 20mg, 5mg
..............................................12
estrace .......................................43
estradiol ptwk 0.025mg/24hr,
0.05mg/24hr, 0.06mg/24hr,
0.1mg/24hr, 37.5mcg/24hr ...43
estradiol ptwk 0.075mg/24hr ....43
estradiol tabs .............................43
estradiol valerate.......................43
estradiol/norethindrone acetate.44
estring .......................................44
Estrogens ..................................43
estropipate.................................44
ethambutol hcl ..........................16
ethosuximide...............................9
etidronate disodium tabs 400mg50
etodolac caps 200mg ..................2
etodolac er ..................................2
etodolac tabs ...............................2
etoposide inj..............................18
eurax .........................................20
evamist......................................44
evista.........................................46
evoxac.......................................36
exalgo tb24 12mg, 8mg ..............3
exalgo tb24 16mg .......................3
exelderm ...................................14
exelon pt24 ...............................11
exelon soln................................11
exemestane ...............................18
exforge......................................32
exforge hct ................................32
exjade........................................56
extavia.......................................36
F
fabrazyme .................................38
factive .........................................8
famciclovir................................24
famotidine inj, susr ...................39
famotidine tabs 20mg, 40mg ....39
fanapt tabs 10mg, 12mg, 6mg, 8mg
..............................................21
fanapt tabs 1mg, 2mg, 4mg ......21
fareston .....................................17
faslodex.....................................18
fazaclo tbdp 100mg, 25mg .......22
felbamate ..................................10
felodipine er..............................31
femhrt low dose ........................44
femring .....................................44
femtrace tabs 0.45mg................44
femtrace tabs 0.9mg..................44
fenofibrate micronized..............34
fenofibrate tabs 145mg, 48mg ..34
fenofibrate tabs 160mg, 54mg ..34
fenoglide ...................................34
fenoprofen calcium .....................2
fentanyl citrate oral transmucosal3
fentanyl pt72 100mcg/hr.............3
fentanyl pt72 12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr ...............3
fentora.........................................3
Fibromyalgia Agents ................36
finacea.......................................37
finasteride tabs 5mg..................40
firmagon inj 120mg ..................47
flarex.........................................51
flavoxate hcl .............................40
flecainide acetate ......................30
flector..........................................2
flovent diskus............................53
flovent hfa.................................53
fluconazole ...............................14
fluconazole in dextrose inj 56mg/ml,
400mg/200ml .......................14
flucytosine ................................14
fludrocortisone acetate..............41
flunisolide soln 0.025% ............53
fluocinolone acetonide crea, oint, soln
..............................................41
fluocinolone acetonide oil ........41
fluocinonide..............................41
fluocinonide-e...........................41
fluoroplex .................................37
fluorouracil crea, inj .................37
fluorouracil external soln..........37
fluoxetine hcl ............................12
fluphenazine decanoate.............21
fluphenazine hcl........................21
flurbiprofen...........................2, 51
flurbiprofen sodium ..................51
flutamide...................................47
fluticasone propionate.........41, 53
fluvastatin caps 20mg ...............34
fluvastatin caps 40mg ...............34
fluvoxamine maleate.................12
fml.............................................51
fml forte ....................................51
focalin xr cp24 10mg, 15mg.....35
focalin xr cp24 20mg................36
folic acid ...................................58
fondaparinux sodium inj 10mg/0.8ml,
5mg/0.4ml, 7.5mg/0.6ml ......28
fondaparinux sodium inj 2.5mg/0.5ml
..............................................28
foradil aerolizer ........................54
forfivo xl...................................11
forteo.........................................50
fortical.......................................50
fosamax plus d..........................50
foscarnet sodium.......................22
fosinopril sodium................30, 32
fosinopril sodium/hydrochlorothiazide
..............................................32
fosrenol chew 1000mg, 500mg 40
fragmin inj 12500unit/0.5ml,
15000unit/0.6ml, 18000unt/0.72ml,
7500unit/0.3ml .....................28
fragmin inj 2500unit/0.2ml.......28
freamine iii 3% .........................57
64
frova..........................................16
furosemide inj, tabs...................33
furosemide oral soln 10mg/ml ..33
fuzeon inj 90mg ........................23
G
GABA Receptor Modulators ....56
gabapentin.................................10
gabitril tabs 12mg .....................10
gabitril tabs 16mg, 4mg ............10
gabitril tabs 2mg .......................10
galantamine hydrobromide .......11
gamastan s/d .............................48
Gamma-aminobutyric Acid (GABA)
Augmenting Agents................9
gammagard liquid.....................48
ganciclovir ................................22
gardasil .....................................49
Gastrointestinal Agents.......38, 39
Gastrointestinal Agents, Other .38
gavilyte-c ..................................39
gavilyte-g..................................39
gavilyte-n/flavor pack...............39
gelnique gel 10% ......................40
gemcitabine hcl inj 1gm ...........17
gemfibrozil ...............................34
generlac.....................................39
gengraf ......................................48
Genitourinary Agents ...............40
Genitourinary Agents, Other ....40
genotropin.................................42
genotropin miniquick inj 0.2mg42
genotropin miniquick inj 0.4mg, 0.8mg,
1mg.......................................42
gentak oint ..................................5
gentamicin sulfate crea, inj, oint,
ophthalmic soln ......................5
gentamicin sulfate/0.9% sodium
chloride inj 1.6mg/ml, 0.9%,
1mg/ml, 0.9% .........................5
geodon ......................................21
gianvi ........................................44
gilenya ......................................36
gleevec tabs 100mg ..................19
gleevec tabs 400mg ..................19
glimepiride tabs 1mg ................26
glimepiride tabs 2mg ................26
glimepiride tabs 4mg ................26
glipizide er tb24 10mg..............26
glipizide er tb24 2.5mg.............26
glipizide er tb24 5mg................26
glipizide tabs 10mg...................26
glipizide tabs 5mg.....................26
glipizide/metformin hcl tabs 2.5mg,
250mg...................................27
glipizide/metformin hcl tabs 2.5mg,
500mg, 5mg, 500mg.............27
glucagen hypokit.......................27
glucagon emergency kit............27
Glucocorticoids...................41, 49
Glucocorticoids/ Mineralocorticoids
..............................................41
Glutamate Reducing Agents .....10
glyburide micronized tabs 1.5mg26
glyburide micronized tabs 3mg 26
glyburide micronized tabs 6mg 26
glyburide tabs 1.25mg ..............26
glyburide tabs 2.5mg ................26
glyburide tabs 5mg ...................26
glyburide/metformin hcl tabs 1.25mg,
250mg...................................27
glyburide/metformin hcl tabs 2.5mg,
500mg, 5mg, 500mg.............27
Glycemic Agents ......................27
glycopyrrolate inj......................38
glycopyrrolate tabs ...................38
glyset.........................................26
golytely .....................................39
granisetron hcl inj 1mg/ml........14
granisetron hcl tabs...................14
griseofulvin microsize susp ......14
griseofulvin microsize tabs.......14
griseofulvin ultramicrosize .......15
gris-peg .....................................14
guanfacine hcl...........................29
H
halflytely bowel prep/flavor packs
..............................................39
halobetasol propionate..............42
halog .........................................42
haloperidol................................21
haloperidol decanoate ...............21
haloperidol lactate.....................21
havrix........................................49
hectorol caps .............................50
helidac.......................................39
heparin sodium .........................28
heparin sodium/nacl 0.45% ......28
hepatasol ...................................57
hepsera......................................24
herceptin ...................................18
hexalen......................................16
Histamine2 (H2) Receptor Antagonists
..............................................39
Hormonal Agents, Stimulant/
Replacement/ Modifying (Adrenal)
........................................41, 42
Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary)
..............................................42
Hormonal Agents, Stimulant/
Replacement/ Modifying (Sex
Hormones/ Modifiers) ....43, 44
Hormonal Agents, Stimulant/
Replacement/ Modifying (Thyroid)
..............................................46
Hormonal Agents, Suppressant
(Adrenal) ..............................46
Hormonal Agents, Suppressant
(Parathyroid) ........................46
Hormonal Agents, Suppressant
(Pituitary) .............................46
Hormonal Agents, Suppressant (Sex
Hormones/ Modifiers) ..........47
Hormonal Agents, Suppressant
(Thyroid) ..............................47
humalog ....................................27
humalog kwikpen .....................27
humalog mix 50/50...................27
humalog mix 50/50 kwikpen ....27
humalog mix 75/25...................27
humalog mix 75/25 kwikpen ....27
humatrope .................................42
humira.......................................48
humulin 70/30.....................27, 28
humulin 70/30 pen....................28
humulin n..................................28
humulin n u-100 pen.................28
humulin r ..................................28
humulin r u-500 (concentrated) 28
hydralazine hcl tabs ..................35
hydrochlorothiazide..................34
hydrocodone bitartrate/acetaminophen
soln .........................................1
hydrocodone bitartrate/acetaminophen
tabs 300mg, 10mg ..................1
hydrocodone bitartrate/acetaminophen
tabs 300mg, 5mg ....................1
hydrocodone bitartrate/acetaminophen
tabs 750mg, 10mg ..................1
hydrocodone bitartrate/homatropine
methylbromide .....................53
hydrocodone/acetaminophen soln1
hydrocodone/acetaminophen tabs
325mg, 10mg, 500mg, 10mg,
500mg, 7.5mg, 650mg, 10mg,
650mg, 7.5mg, 660mg, 10mg 1
hydrocodone/acetaminophen tabs
325mg, 5mg............................1
hydrocodone/acetaminophen tabs
325mg, 7.5mg, 500mg, 2.5mg,
500mg, 5mg............................1
hydrocodone/acetaminophen tabs
750mg, 7.5mg.........................1
65
hydrocodone/ibuprofen...............1
hydrocortisone ....................42, 50
hydrocortisone butyrate ............42
hydrocortisone lotn, tabs...........42
hydrocortisone oint ...................42
hydrocortisone valerate.............42
hydromorphone hcl inj 500mg/50ml
................................................4
hydromorphone hcl tabs .............4
hydroxychloroquine sulfate ......19
hydroxyurea..............................17
hydroxyzine hcl ........................13
hydroxyzine pamoate................13
I
ibandronate sodium...................50
ibuprofen susp.............................2
ibuprofen tabs 400mg, 600mg, 800mg
................................................2
iclusig tabs 15mg ......................17
iclusig tabs 45mg ......................17
imipenem/cilastatin.....................7
imipramine hcl..........................13
imipramine pamoate caps 100mg,
150mg, 75mg........................13
imipramine pamoate caps 125mg13
imiquimod.................................37
imitrex soln...............................16
Immune Suppressants ...............47
Immunizing Agents, Passive ....48
Immunological Agents .............47
Immunomodulators...................48
imovax rabies (h.d.c.v.) ............49
incivek ......................................24
increlex .....................................42
indapamide ...............................34
indocin susp ................................2
indomethacin caps ......................2
indomethacin er ..........................2
infanrix .....................................49
Inflammatory Bowel Disease Agents
..............................................49
inlyta .........................................18
innopran xl................................31
Insulins .....................................27
intelence tabs 100mg ................22
intelence tabs 200mg ................22
intralipid ...................................57
intron-a inj 6000000unit/ml......24
intron-a w/diluent inj 10mu ......24
introvale....................................44
intuniv.......................................36
invanz .........................................7
invega sustenna inj 117mg/0.75ml,
156mg/ml, 234mg/1.5ml ......21
invega sustenna inj 39mg/0.25ml,
78mg/0.5ml ..........................21
invega tb24 1.5mg, 3mg ...........21
invega tb24 6mg .......................21
invega tb24 9mg .......................21
invirase caps .............................23
invirase tabs ..............................23
ionosol-b/dextrose 5% ..............57
ipol inactivated ipv ...................49
ipratropium bromide inhalation soln
..............................................54
ipratropium bromide nasal soln 54
ipratropium bromide/albuterol sulfate
..............................................55
irbesartan ............................30, 32
irbesartan/hydrochlorothiazide .32
irinotecan inj 100mg/5ml..........18
Irritable Bowel Syndrome Agents39
isentress chew...........................23
isentress tabs .............................23
isolyte-p/dextrose 5% ...............57
isoniazid tabs ............................16
isordil titradose .........................35
isosorbide dinitrate ...................35
isosorbide dinitrate er ...............35
isosorbide mononitrate er .........35
isosorbide mononitrate tabs 10mg35
isosorbide mononitrate tabs 20mg35
isotonic gentamicin inj 0.8mg/ml, 0.9%
................................................5
isradipine ..................................31
istalol ........................................52
itraconazole...............................15
ixempra kit inj 45mg.................18
ixiaro.........................................49
J
jakafi .........................................18
jalyn ..........................................40
jantoven ....................................28
janumet .....................................27
janumet xr.................................27
januvia ......................................26
jevtana.......................................18
jinteli.........................................44
jolivette .....................................46
junel 1.5/30 ...............................44
junel 1/20 ..................................44
junel fe 1.5/30...........................44
junel fe 1/20..............................45
K
kaletra soln................................23
kaletra tabs 100mg, 25mg.........23
kaletra tabs 200mg, 50mg.........23
kalydeco....................................55
kanamycin sulfate.......................5
kariva ........................................45
kcl 0.075%/d5w/nacl 0.45%.....57
kcl 0.15%/d5w/lr ......................57
kcl 0.15%/d5w/nacl 0.2%.........57
kcl 0.15%/d5w/nacl 0.9%.........57
kcl 0.3%/d5w/nacl 0.45%.........57
kcl 0.3%/d5w/nacl 0.9%...........57
kelnor 1/35................................45
kenalog .....................................42
ketoconazole crea, sham, tabs...15
ketoconazole foam....................15
ketoprofen...................................2
ketoprofen er...............................2
ketorolac tromethamine ........2, 51
ketorolac tromethamine inj 15mg/ml,
30mg/ml .................................2
ketorolac tromethamine tabs.......2
kineret .......................................48
kionex .......................................56
klor-con 10................................56
klor-con 8..................................56
klor-con m15 ............................56
klor-con m20 ............................56
kombiglyze xr tb24 1000mg, 2.5mg
..............................................27
kombiglyze xr tb24 1000mg, 5mg,
500mg, 5mg..........................27
kristalose...................................39
kuvan ........................................38
L
labetalol hcl tabs .......................31
laclotion ....................................37
lactated ringers irrigation..........58
lactated ringers viaflex..............58
lactulose....................................39
lamictal odt tbdp 100mg, 25mg 10
lamictal odt tbdp 200mg ...........10
lamictal starter/not taking
carbamazepine......................10
lamictal starter/taking
carbamazepine/not taking valproate
..............................................10
lamictal starter/taking valproate10
lamictal xr kit 0.........................10
lamictal xr tb24 100mg, 25mg, 50mg
..............................................10
lamictal xr tb24 200mg.............10
lamictal xr tb24 250mg.............10
lamivudine ................................22
lamivudine/zidovudine .............22
lamotrigine................................10
66
lamotrigine er tb24 100mg, 25mg,
50mg.....................................10
lamotrigine er tb24 200mg .......10
lamotrigine er tb24 250mg, 300mg
..............................................10
lanoxin tabs...............................32
lansoprazole..............................40
lantus.........................................28
lantus solostar ...........................28
lastacaft.....................................51
latanoprost ................................52
latuda tabs 120mg, 20mg, 80mg21
latuda tabs 40mg.......................21
Laxatives...................................39
leena..........................................45
leflunomide...............................48
lescol xl.....................................34
lessina .......................................45
letairis .......................................55
letrozole ....................................18
leucovorin calcium inj 100mg, 350mg
..............................................17
leucovorin calcium tabs ............17
leukeran ....................................17
leukine ......................................29
leuprolide acetate......................47
levalbuterol 1.25 MG/0.5ML....54
levatol .......................................31
levemir ......................................28
levemir flexpen.........................28
levetiracetam er...........................9
levetiracetam inj 500mg/5ml ......9
levetiracetam oral soln, tabs .......9
levobunolol hcl soln 0.5% ........52
levocarnitine .............................58
levocetirizine dihydrochloride tabs
..............................................53
levofloxacin ................................8
levofloxacin in d5w inj 5%,
500mg/100ml .........................8
levonorgestrel/ethinyl estradiol 45
levora 0.15/30-28......................45
levothroid..................................46
levothyroxine sodium ...............46
levoxyl ......................................46
lexiva susp ................................23
lexiva tabs.................................23
lialda .........................................49
lidocaine hcl external soln ..........4
lidocaine hcl inj 1% ....................4
lidocaine hcl jelly........................4
lidocaine oint ..............................4
lidocaine viscous.........................4
lidocaine/prilocaine crea.............4
lidoderm......................................4
lincocin .......................................6
lindane lotn ...............................20
lindane sham.............................20
linzess .......................................39
liothyronine sodium..................46
lipofen caps 150mg...................34
lisinopril..............................30, 32
lisinopril/hydrochlorothiazide ..32
lithium carbonate ......................25
lithium carbonate er ..................25
lithium citrate............................25
livalo .........................................34
Local Anesthetics .......................4
locoid lipocream .......................42
lodosyn .....................................20
lofibra tabs 160mg ....................34
loperamide hcl caps ..................38
lorazepam intensol....................25
lorazepam tabs 0.5mg ...............25
lorazepam tabs 1mg ..................25
lorazepam tabs 2mg ..................25
lorzone ......................................55
losartan potassium ..............30, 33
losartan potassium/hydrochlorothiazide
..............................................33
lotemax .....................................51
lotronex.....................................39
lovastatin...................................34
lovaza........................................34
lovenox .....................................28
low-ogestrel ..............................45
loxapine succinate.....................21
lufyllin ......................................54
lumigan soln 0.01% ..................52
lumigan soln 0.03% ..................52
lunesta.......................................56
lupron depot inj 22.5mg, 3.75mg,
30mg, 45mg, 7.5mg..............47
lupron depot-ped inj 11.25mg, 15mg
..............................................47
lutera .........................................45
lyrica caps 100mg, 150mg, 200mg,
25mg, 50mg, 75mg.................9
lyrica caps 225mg, 300mg..........9
lyrica soln ...................................9
lysodren ....................................46
M
macrodantin caps 25mg ..............6
Macrolides ..................................8
malathion ..................................20
maprotiline hcl..........................11
marlissa.....................................45
marplan .....................................12
Mast Cell Stabilizers.................55
matulane ...................................17
matzim la ..................................31
maxair autohaler .......................54
maxalt .......................................16
maxalt-mlt.................................16
maxidex ....................................51
meclizine hcl.............................13
meclofenamate sodium caps 100mg
................................................2
meclofenamate sodium caps 50mg
................................................2
medroxyprogesterone acetate inj46
medroxyprogesterone acetate tabs46
mefenamic acid...........................2
mefloquine hcl ..........................19
megestrol acetate ......................46
meloxicam susp ..........................3
meloxicam tabs...........................2
menactra ...................................49
menest.......................................44
menomune-a/c/y/w-135 ............49
menostar ...................................44
mentax ......................................15
menveo .....................................49
meperidine hcl inj 100mg/ml, 25mg/ml,
50mg/ml .................................4
meperitab ....................................4
meprobamate ............................25
mepron......................................19
mercaptopurine .........................48
meropenem inj 500mg ................7
mesalamine kit..........................49
mesna........................................18
mesnex tabs ..............................18
mestinon syrp............................16
mestinon timespan ....................16
Metabolic Bone Disease Agents50
metadate cd cpcr 10mg, 20mg..36
metadate cd cpcr 60mg .............36
metadate er................................36
metaproterenol sulfate syrp ......54
metformin hcl er tb24 500mg ...26
metformin hcl er tb24 750mg ...26
metformin hcl tabs 1000mg......26
metformin hcl tabs 500mg........26
metformin hcl tabs 850mg........26
methadone hcl soln 5mg/5ml......3
methadone hcl tabs .....................3
methamphetamine hcl...............35
methazolamide..........................33
methenamine hippurate...............6
methimazole .............................47
methitest ...................................43
methocarbamol .........................55
methotrexate .............................48
67
methotrexate sodium inj 25mg/ml48
methscopolamine bromide........38
methyclothiazide.......................34
methyldopa .........................29, 33
methyldopa/hydrochlorothiazide33
methylphenidate hcl..................36
methylphenidate hcl cd cpcr 10mg
..............................................36
methylphenidate hcl cd cpcr 50mg,
60mg.....................................36
methylphenidate hcl er tbcr 20mg36
methylphenidate hydrochloride 36
methylprednisolone ..................42
methylprednisolone acetate ......42
methylprednisolone dose pack..42
methylprednisolone sodiumsuccinate
inj 125mg, 40mg ..................42
methylprednisolone sodiumsuccinate
inj 1gm .................................42
metipranolol..............................52
metoclopramide hcl ..................13
metolazone................................34
metoprolol succinate er.............31
metoprolol tartrate tabs.............31
metoprolol/hydrochlorothiazide33
metrogel ......................................6
metronidazole caps .....................6
metronidazole crea, gel, lotn, tabs6
metronidazole in nacl 0.79% ......6
metronidazole vaginal.................6
mexiletine hcl ...........................30
micardis ..............................30, 33
micardis hct ..............................33
miconazole 3.............................15
microgestin 1.5/30 ....................45
microgestin 1/20 .......................45
microgestin fe ...........................45
microgestin fe 1.5/30 ................45
midodrine hcl............................29
migergot....................................15
migranal....................................16
millipred .............................42, 51
minitran.....................................35
minocycline hcl.....................9, 36
minocycline hcl caps ..................9
minoxidil...................................35
mirtazapine .........................11, 12
mirtazapine odt tbdp 30mg, 45mg12
misoprostol tabs 200mcg ..........39
mitomycin inj 20mg..................18
mitoxantrone hcl .......................17
m-m-r ii w/diluent 10 dose .......49
modafinil...................................56
moexipril hcl.............................30
moexipril/hydrochlorothiazide .33
Molecular Target Inhibitors......18
mometasone furoate..................42
Monoamine Oxidase B (MAO-B)
Inhibitors ..............................20
Monoamine Oxidase Inhibitors 12
Monoclonal Antibodies ............19
mononessa ................................45
montelukast sodium chew, tabs 53
monurol.......................................6
Mood Stabilizers.......................25
morphine sulfate er cp24 ............3
morphine sulfate er tb12 .............3
morphine sulfate soln, tabs .........3
moviprep...................................39
moxeza........................................8
ms contin tb12 100mg, 15mg, 30mg,
60mg.......................................3
multaq .......................................30
Multiple Sclerosis Agents.........36
mupirocin oint.............................6
mustargen .................................18
mycamine .................................15
mycobutin .................................16
mycophenolate mofetil .............48
myfortic tbec 180mg.................48
myfortic tbec 360mg.................48
myozyme ..................................38
N
nabumetone.................................3
nadolol ................................31, 33
nadolol/bendroflumethiazide ....33
nafcillin sodium inj 1gm.............7
naftin crea 1%...........................15
naftin gel...................................15
naglazyme.................................38
nalbuphine hcl.............................4
nalfon........................................34
naloxone hcl................................4
naltrexone hcl .............................4
namenda soln ............................11
namenda tabs ............................11
namenda titration pak ...............11
naproxen .................................3, 5
naproxen dr .................................3
naproxen sodium tabs 275mg, 550mg
................................................3
naratriptan hcl ...........................16
nasonex .....................................53
natacyn......................................15
nateglinide ................................26
nebupent ...................................19
necon 0.5/35-28 ........................45
necon 1/35 ................................45
necon 7/7/7 ...............................45
nefazodone hcl..........................12
neomycin sulfate.........................5
neomycin/bacitracin/polymyxin50
neomycin/polymyxin/bacitracin/hydroc
ortisone.................................50
neomycin/polymyxin/dexamethasone
..............................................50
neomycin/polymyxin/gramicidin51
neomycin/polymyxin/hc ...........52
neomycin/polymyxin/hydrocortisone
........................................51, 52
neomycin/polymyxin/hydrocortisone
otic susp................................52
nephramine ...............................58
neulasta .....................................29
neumega....................................29
neupogen...................................29
nevanac .....................................51
nevirapine tabs..........................22
nexavar .....................................19
nexium cpdr ..............................40
nexium i.v. ................................40
nexium pack 10mg, 20mg, 40mg40
next choice................................46
niacor ........................................34
niaspan......................................34
nicardipine hcl caps ..................31
nicotrol ns ...................................5
nifediac cc tb24 90mg...............31
nifedical xl ................................32
nifedipine..................................32
nifedipine er..............................32
nilandron...................................47
nimodipine................................32
nisoldipine ................................32
nisoldipine er ............................32
nitro-bid ....................................35
nitrofurantoin..............................6
nitrofurantoin macrocrystalline caps
50mg.......................................6
nitrofurantoin monohydrate........6
nitroglycerin .............................35
nitroglycerin transdermal..........35
nitrolingual pumpspray.............35
nitromist....................................35
nitrostat .....................................35
nizatidine ..................................39
N-methyl-D-aspartate (NMDA)
Receptor Antagonist.............11
Nonsteroidal Anti-inflammatory Drugs
............................................2, 5
nora-be......................................46
norditropin flexpro....................42
norditropin nordiflex pen..........43
norethindrone acetate................46
68
normosol-m in d5w...................58
normosol-r in d5w ....................58
norpace cr cp12 100mg.............30
nortrel 0.5/35 (28).....................45
nortrel 1/35 ...............................45
nortrel 7/7/7 ..............................45
nortriptyline hcl caps ................13
norvir ........................................23
novarel ......................................43
novolin 70/30............................28
novolin n...................................28
novolin r....................................28
novolog .....................................28
novolog flexpen ........................28
novolog mix 70/30....................28
novolog mix 70/30 prefilled flexpen
..............................................28
noxafil.......................................15
nucynta ...................................3, 4
nucynta er tb12 100mg, 150mg, 200mg,
250mg.....................................3
nucynta er tb12 50mg .................3
nuedexta....................................36
nutropin aq pen .........................43
nuvigil.......................................56
nystatin crea, oint, susp, tabs ....15
nystatin/triamcinolone ..............37
nystop .......................................15
O
ocella.........................................45
octreotide acetate inj 1000mcg/ml,
200mcg/ml, 500mcg/ml .......47
octreotide acetate inj 100mcg/ml,
50mcg/ml..............................47
ofloxacin ophthalmic soln, otic soln
................................................8
ofloxacin tabs..............................8
olanzapine...........................12, 21
olanzapine odt...........................21
olanzapine/fluoxetine caps 25mg,
12mg, 50mg, 12mg, 50mg, 6mg
..............................................12
olanzapine/fluoxetine caps 25mg, 3mg
..............................................12
olanzapine/fluoxetine caps 25mg, 6mg
..............................................12
omeprazole cpdr .......................40
omnitrope..................................43
ondansetron hcl soln .................14
ondansetron hcl tabs 24mg .......14
ondansetron hcl tabs 4mg, 8mg 14
ondansetron odt tbdp 4mg ........14
ondansetron odt tbdp 8mg ........14
onfi..............................................9
onglyza tabs 2.5mg ...................26
onglyza tabs 5mg ......................26
onmel ........................................15
onsolis film 200mcg ...................3
onsolis film 400mcg ...................3
opana er (crush resistant) tb12 10mg,
20mg, 30mg, 5mg...................3
opana er (crush resistant) tb12 40mg
................................................3
Ophthalmic Agents ...................50
Ophthalmic Agents, Other........50
Ophthalmic Anti-allergy Agents51
Ophthalmic Antiglaucoma Agents52
Ophthalmic Anti-inflammatories51
Ophthalmic Prostaglandin and
Prostamide Analogs..............52
Opioid Analgesics, Long-acting .3
Opioid Analgesics, Short-acting.4
Opioid Antagonists .....................4
orap ...........................................21
orapred odt..........................42, 51
orencia ......................................48
orfadin.......................................38
orphenadrine citrate ............55, 56
orphenadrine citrate er ..............56
orphenadrine/asa/caffeine...........1
orsythia .....................................45
osmoprep ..................................56
Otic Agents ...............................52
oxandrolone tabs 10mg.............43
oxandrolone tabs 2.5mg............43
oxaprozin ....................................3
oxcarbazepine tabs....................11
oxistat .......................................15
oxsoralen ultra ..........................37
oxybutynin chloride..................40
oxybutynin chloride er..............40
oxycodone hcl caps.....................4
oxycodone hcl conc ....................4
oxycodone hcl soln .....................4
oxycodone hcl tabs 10mg, 20mg 4
oxycodone hcl tabs 15mg, 30mg, 5mg
................................................4
oxycodone/acetaminophen caps .1
oxycodone/acetaminophen tabs 325mg,
10mg, 325mg, 2.5mg, 325mg, 7.5mg
................................................2
oxycodone/acetaminophen tabs 325mg,
5mg.........................................1
oxycodone/acetaminophen tabs 500mg,
7.5mg......................................1
oxycodone/acetaminophen tabs 650mg,
10mg.......................................1
oxycodone/aspirin.......................2
oxycodone/ibuprofen ..................3
oxycontin tb12 10mg, 15mg, 20mg,
30mg, 40mg, 60mg ................3
oxycontin tb12 80mg ..................3
oxymorphone hydrochloride...3, 4
oxymorphone hydrochloride er tb12
15mg.......................................3
oxytrol.......................................40
P
pacerone tabs 100mg ................30
pacerone tabs 200mg ................30
paclitaxel inj 300mg/50ml ........18
pamidronate disodium inj 6mg/ml50
pancreaze ..................................38
pandel .......................................42
panretin .....................................19
pantoprazole sodium tbec .........40
Parasympathomimetics.............16
paromomycin sulfate ..................5
paroxetine hcl ...........................12
paroxetine hcl er .......................12
pataday......................................51
patanase ....................................53
patanol ......................................51
paxil ..........................................12
Pediculicides/ Scabicides..........20
pedi-dri .....................................15
pedvax hib ................................49
peganone...................................11
pegasys inj 180mcg/0.5ml ........24
pegasys inj 180mcg/ml .............24
pegasys proclick inj 135mcg/0.5ml
..............................................24
peg-intron inj 50mcg/0.5ml ......24
peg-intron redipen ....................24
penicillin g potassium in iso-osmotic
dextrose inj 0, 60000unit/ml...7
penicillin g potassium inj 5mu....7
penicillin g sodium .....................7
penicillin v potassium.................8
pennsaid......................................3
pentasa ......................................49
pentazocine/acetaminophen........2
pentazocine/naloxone hcl ...........2
pentoxifylline er........................32
perforomist ...............................54
perindopril erbumine ................30
periogard...................................36
perjeta .......................................18
permethrin.................................20
perphenazine.......................12, 13
perphenazine/amitriptyline .......12
pertzye ......................................38
pexeva.......................................13
phenadoz...................................13
69
phenelzine sulfate .....................12
phenobarbital elix .......................9
phenobarbital tabs 100mg, 15mg, 60mg
................................................9
phenobarbital tabs 16.2mg, 30mg,
64.8mg, 97.2mg......................9
phenobarbital tabs 32.4mg..........9
phenytek ...................................11
phenytoin chew.........................11
phenytoin sodium extended ......11
phenytoin susp ..........................11
phisohex....................................37
phoslyra ....................................41
Phosphate Binders ....................40
phospholine iodide....................52
pilocarpine hcl ..........................37
pilocarpine hydrochloride.........37
pilopine hs ................................52
pindolol.....................................31
pioglitazone hcl...................26, 27
pioglitazone hcl/metformin hcl.27
pioglitazone hcl-glimepiride.....27
piperacillin sodium/tazobactam sodium
inj 3gm, 0.375gm ...................8
piroxicam....................................3
plasma-lyte-148 ........................56
plasma-lyte-56/d5w ..................58
Platelet Modifying Agents........29
podofilox...................................37
polyethylene glycol 3350 powd39
portia-28 ...................................45
potassium chloride..............56, 58
potassium chloride 0.15% /nacl 0.45%
viaflex...................................56
potassium chloride 0.15% d5w/nacl
0.33% ...................................58
potassium chloride 0.15% d5w/nacl
0.45% viaflex ......................58
potassium chloride 0.15% nacl 0.9%
..............................................56
potassium chloride 0.22% d5w/nacl
0.45% ...................................58
potassium chloride 0.224%/dextrose
5% viaflex ............................58
potassium chloride 0.3%/d5w...58
potassium chloride er................56
potassium citrate.......................40
potiga ..........................................9
pradaxa .....................................28
pramipexole dihydrochloride....20
prandimet ..................................27
prandin tabs 0.5mg, 1mg ..........26
prandin tabs 2mg ......................26
pravastatin sodium....................34
prazosin hcl...............................30
pred mild...................................52
pred-g........................................51
prednicarbate ............................42
prednisolone acetate .................52
prednisolone sodium phosphate42, 52
prednisone.................................42
prednisone intensol ...................42
prefest .......................................45
pregnyl w/diluent benzyl alcohol/nacl
..............................................43
premarin crea ............................44
premarin tabs 0.3mg, 0.45mg, 0.625mg,
0.9mg....................................44
premarin tabs 1.25mg ...............44
premasol ...................................58
premphase.................................45
prempro.....................................45
prevalite powd ..........................34
previfem....................................45
prevpac .....................................39
prezista tabs 150mg, 400mg, 600mg,
800mg...................................23
prezista tabs 75mg ....................23
primidone..................................10
pristiq........................................13
proair hfa ..................................54
probenecid ................................15
probenecid/colchicine...............15
procalamine ..............................58
prochlorperazine edisylate........13
prochlorperazine maleate..........13
procrit inj 10000unit/ml, 2000unit/ml,
3000unit/ml, 4000unit/ml.....29
procrit inj 20000unit/ml, 40000unit/ml
..............................................29
proctocream hc .........................50
procto-pak.................................42
proctozone-hc ...........................42
progesterone..............................46
Progestins .................................46
proglycem .................................27
prolastin-c .................................55
proleukin...................................18
prolia.........................................50
promacta ...................................29
promethazine hcl.......................13
promethazine vc..................53, 55
promethazine vc/codeine ..........53
promethazine/codeine...............53
promethazine/dextromethorphan54
promethegan supp 25mg, 50mg13
propafenone hcl ........................30
propafenone hcl er ....................30
Prophylactic..............................16
propranolol hcl er......................31
propranolol hcl tabs ..................31
propranolol/hydrochlorothiazide33
propylthiouracil ........................47
proquad .....................................49
prosol ........................................58
Protectants ................................39
Proton Pump Inhibitors.............39
protopic oint 0.03% ..................37
protopic oint 0.1% ....................37
protriptyline hcl ........................13
proventil hfa..............................54
Psychotherapeutic Agents.........36
pulmicort flexhaler ...................53
Pulmonary Antihypertensives...55
pulmozyme ...............................55
pylera ........................................39
pyridostigmine bromide............16
Q
qualaquin ..................................19
quasense....................................45
quetiapine fumarate ..................21
quinapril hcl..............................30
quinapril/hydrochlorothiazide ..33
quinidine gluconate er ..............30
quinidine sulfate .......................30
quinidine sulfate er ...................30
quinine sulfate ..........................19
Quinolones..................................8
qvar ...........................................53
R
rabavert .....................................49
ramipril .....................................30
ranexa .......................................32
ranitidine hcl caps, syrp, tabs....39
rapaflo.......................................40
rapamune soln...........................48
rapamune tabs 0.5mg................48
rapamune tabs 1mg, 2mg..........48
rebif...........................................36
rebif titration pack ....................36
reclast........................................50
reclipsen....................................45
recombivax hb inj 10mcg/ml,
40mcg/ml..............................49
rectiv.........................................35
regranex ....................................37
relenza diskhaler.......................23
relistor inj 12mg/0.6ml .............38
relpax ........................................16
remicade ...................................48
renvela pack 0.8gm...................41
renvela pack 2.4gm...................41
70
renvela tabs ...............................41
reprexain .....................................2
rescriptor tabs 100mg ...............22
rescriptor tabs 200mg ...............22
reserpine ...................................33
Respiratory Tract Agents....53, 55
Respiratory Tract Agents, Other55
restasis ......................................50
Retinoids...................................19
retrovir iv infusion....................22
revatio tabs................................55
revlimid caps 10mg, 5mg .........17
revlimid caps 15mg, 25mg .......17
reyataz caps 100mg ..................23
reyataz caps 150mg, 200mg, 300mg
..............................................23
rheumatrex................................48
rhinocort aqua...........................53
ribapak tabs 400mg...................24
ribasphere caps .........................24
ribasphere tabs 200mg ..............24
ribasphere tabs 400mg, 600mg .24
ribavirin ....................................24
ridaura.......................................48
rifampin ....................................16
rifater ........................................16
rilutek........................................36
rimantadine hcl .........................23
risperdal consta inj 12.5mg, 25mg21
risperdal consta inj 37.5mg.......21
risperdal consta inj 50mg..........21
risperidone ................................21
risperidone odt ..........................21
rituxan.......................................19
rivastigmine tartrate..................11
rizatriptan benzoate...................16
ropinirole er ..............................20
ropinirole hcl.............................20
rotateq .......................................49
roxicet .........................................2
rozerem .....................................56
S
sabril pack.................................10
sabril tabs..................................10
saizen click.easy .......................43
samsca.......................................56
sanctura xr ................................40
sancuso .....................................14
sandostatin lar depot .................47
santyl.........................................37
saphris.......................................21
savella .......................................36
savella titration pack.................36
Selective Estrogen Receptor Modifying
Agents ..................................46
selegiline hcl .............................20
selenium sulfide lotn.................37
selzentry tabs 150mg ................23
selzentry tabs 300mg ................23
sensipar .....................................46
serevent diskus..........................54
seroquel xr tb24 150mg, 200mg12
seroquel xr tb24 300mg, 400mg, 50mg
..............................................12
Serotonin (5-HT) 1b/1d Receptor
Agonists................................16
Serotonin/ Norepinephrine Reuptake
Inhibitors ..............................12
sertraline hcl .............................13
sildenafil citrate ........................55
silenor .......................................13
silver sulfadiazine .......................8
simcor .................................33, 34
simcor tb24 1000mg, 40mg, 500mg,
40mg.....................................34
simponi .....................................48
simvastatin tabs 10mg, 20mg, 40mg,
5mg.......................................34
simvastatin tabs 80mg ..............34
singulair ....................................53
Skeletal Muscle Relaxants........55
sklice.........................................20
Sleep Disorder Agents ..............56
Sleep Disorders, Other..............56
Smoking Cessation Agents.........5
Sodium Channel Agents ...........10
sodium chloride ........................56
sodium chloride 0.45% viaflex.56
sodium chloride 0.9% ...............56
sodium sulfacetamide .................9
solaraze .....................................37
solu-cortef inj 100mg................42
solu-cortef inj 250mg................42
soma tabs 250mg ......................56
somatuline depot inj 120mg/0.5ml,
60mg/0.2ml ..........................47
somavert ...................................47
soriatane....................................37
sorine ........................................30
sotalol hcl (af) tabs 120mg .......30
sotalol hcl tabs 160mg, 240mg, 80mg
..............................................30
spectracef tabs 400mg ................7
spiriva handihaler .....................54
spironolactone...........................33
spironolactone/hydrochlorothiazide
..............................................33
sporanox soln............................15
sprintec 28 ................................45
sprycel tabs 100mg, 50mg, 70mg19
sprycel tabs 140mg, 80mg ........19
sprycel tabs 20mg .....................19
sronyx .......................................45
ssd...............................................9
SSRIs/ SNRIs ...........................25
stagesic .......................................2
stalevo 100................................20
stalevo 125................................20
stalevo 150................................20
stalevo 200................................20
stalevo 50..................................20
stalevo 75..................................20
stavudine caps...........................23
stavudine solr............................23
stavzor cpdr 500mg ..................10
stelara........................................38
sterile water irrigation...............58
stivarga .....................................18
strattera .....................................36
striant ........................................43
stribild.......................................23
stromectol .................................19
suboxone.................................4, 5
suboxone film 12mg, 3mg ..........5
suboxone film 4mg, 1mg ............5
sucralfate...................................39
sulfacetamide sodium ...........9, 51
sulfacetamide sodium susp .........9
sulfacetamide sodium/prednisolone
sodium phosphate.................51
sulfadiazine.................................9
sulfamethoxazole/trimethoprim..9
sulfamethoxazole/trimethoprim ds
................................................9
sulfamylon crea ..........................6
sulfasalazine tabs ......................50
sulfazine ec ...............................50
Sulfonamides ........................8, 50
sulindac.......................................3
sumatriptan succinate inj 6mg/0.5ml
..............................................16
sumatriptan succinate tabs ........16
suprax chew, tabs........................7
suprax susr 100mg/5ml...............7
suprep bowel prep.....................56
sustiva .......................................22
sutent caps 12.5mg ...................19
sutent caps 25mg, 50mg ...........19
sylatron .....................................24
symbicort ..................................55
symbyax caps 25mg, 12mg, 50mg,
12mg.....................................12
symbyax caps 25mg, 3mg ........12
symbyax caps 25mg, 6mg ........12
71
symbyax caps 50mg, 6mg ........12
symlinpen 120...........................26
symlinpen 60 ............................26
synalgos-dc .................................2
synarel.......................................47
synercid.......................................6
synribo ......................................17
synthroid ...................................46
T
tabloid .......................................17
taclonex.....................................38
tacrolimus caps 0.5mg ..............48
tacrolimus caps 1mg .................48
tacrolimus caps 5mg .................48
tamiflu caps 45mg, 75mg .........23
tamoxifen citrate.......................17
tamsulosin hcl ...........................40
tarceva tabs 100mg, 150mg ......19
tarceva tabs 25mg .....................19
targretin.....................................19
tarka ..........................................33
tasigna.......................................19
tasmar .......................................20
taxotere inj 80mg/4ml...............18
tazorac.......................................38
taztia xt .....................................32
teflaro inj 400mg ........................7
tegretol......................................11
tegretol-xr .................................11
tekamlo .....................................33
tekturna ...............................32, 33
tekturna hct ...............................33
temazepam ................................25
terazosin hcl..............................30
terbinafine hcl tabs....................15
terbutaline sulfate .....................54
terconazole crea 0.4%...............15
terconazole crea 0.8%...............15
terconazole supp .......................15
testosterone cypionate...............43
testosterone enanthate...............43
testred .......................................43
tetanus toxoid adsorbed ............49
tetanus/diphtheria toxoids-adsorbed
adult......................................49
tetracycline hcl............................9
Tetracyclines...............................9
tev-tropin ..................................43
thalitone ....................................34
thalomid caps 100mg, 50mg.....17
thalomid caps 150mg, 200mg...17
theophylline cr ..........................54
theophylline er tb12 300mg, 450mg
..............................................54
theophylline er tb24 ..................54
Therapeutic Nutrients/ Minerals/
Electrolytes...........................56
thermazene..................................9
thioridazine hcl .........................21
thiothixene ................................21
tiagabine hydrochloride ............10
ticlopidine hcl ...........................29
tikosyn ......................................31
timolol maleate ...................16, 52
timolol maleate ophthalmic gel forming
..............................................52
tinidazole ..................................20
tirosint.......................................46
tizanidine hcl.......................22, 56
tobi..............................................5
tobradex oint ...............................5
tobradex st ................................51
tobramycin sulfate inj 10mg/ml,
80mg/2ml ...............................5
tobramycin sulfate ophthalmic soln
................................................5
tobramycin/dexamethasone ......51
tobrex oint...................................5
tolazamide tabs 500mg .............26
tolbutamide ...............................26
tolmetin sodium ..........................3
tolterodine tartrate.....................40
topiramate .................................10
torsemide tabs ...........................33
toviaz ........................................40
tracleer tabs 125mg...................55
tracleer tabs 62.5mg..................55
tradjenta ....................................27
tramadol hcl ............................3, 4
tramadol hcl er tb24....................3
tramadol hydrochloride/acetaminophen
................................................2
trandolapril ...............................30
tranexamic acid.........................29
transderm-scop..........................13
tranylcypromine sulfate ............12
travasol .....................................58
travatan z ..................................52
trazodone hcl tabs 100mg, 150mg,
50mg.....................................12
trazodone hcl tabs 300mg .........12
treanda ......................................18
Treatment-Resistant..................22
trelstar depot mixject ................47
trelstar la mixject ......................47
tretinoin caps.............................19
tretinoin crea, gel ......................19
trexall tabs 10mg, 15mg ...........48
triamcinolone acetonide......42, 53
triamcinolone in orabase...........37
triamterene/hydrochlorothiazide33
tribenzor....................................33
Tricyclics ..................................13
trifluoperazine hcl.....................21
trifluridine.................................24
trihexyphenidyl hcl tabs............20
tri-legest fe................................45
trileptal susp..............................11
trilipix .......................................34
trilyte.........................................39
trimethobenzamide hcl caps .....13
trimethoprim .........................6, 51
trimethoprim sulfate/polymyxin b
sulfate ...................................51
trimipramine maleate................13
trinessa......................................45
tri-previfem...............................45
tri-sprintec.................................45
trivora-28 ..................................45
trizivir .......................................23
trospium chloride......................40
trospium chloride er..................40
truvada ......................................23
tudorza pressair.........................54
twinject inj 0.3mg/0.3ml...........54
twinrix.......................................49
twynsta......................................33
tygacil .........................................6
tykerb........................................19
typhim vi...................................49
tysabri .......................................36
tyzeka........................................24
tyzine ........................................55
tyzine pediatric nasal drops ......55
U
u-cort.........................................42
uloric.........................................15
ultresa .......................................38
unithroid ...................................46
ursodiol caps.............................39
ursodiol tabs..............................39
V
Vaccines ...................................48
vagifem .....................................44
valacyclovir hcl ........................24
valcyte tabs ...............................22
valproate sodium ......................10
valproic acid .............................10
valsartan/hydrochlorothiazide ..33
vancomycin hcl caps...................6
vancomycin hcl inj 1000mg, 10gm,
72
500mg.....................................6
vandazole....................................6
vaqta inj 25unit/0.5ml...............49
varivax ......................................49
vascepa .....................................34
Vasodilating Agents .................35
Vasodilators, Direct-acting Arterial
........................................34, 35
Vasodilators, Direct-acting Arterial/
Venous..................................34
vectibix .....................................18
vectical......................................38
velcade......................................18
velivet .......................................45
venlafaxine hcl....................13, 25
venlafaxine hcl er................13, 25
ventavis soln 10mcg/ml ............55
ventolin hfa...............................54
veramyst ...................................53
verapamil hcl er ........................32
verapamil hcl tabs.....................32
veregen .....................................38
vesicare .....................................40
vestura.......................................45
vexol .........................................52
vfend iv.....................................15
viagra ........................................35
victoza.......................................27
victrelis .....................................24
vidaza........................................18
videx pediatric solr 2gm ...........23
vigamox ......................................8
viibryd kit .................................12
viibryd tabs ...............................12
vimpat inj..................................11
vimpat oral soln ........................11
vimpat tabs................................11
vincasar pfs ...............................18
viokace......................................38
viracept .....................................23
viramune susp...........................22
viramune xr...............................22
virazole .....................................24
viread powd ..............................23
viread tabs.................................23
Vitamin B Complex..................58
Vitamin D .................................58
Vitamins ...................................58
vivelle-dot pttw 0.025mg/24hr,
0.0375mg/24hr .....................44
vivelle-dot pttw 0.05mg/24hr,
0.1mg/24hr ...........................44
voltaren .....................................38
voriconazole inj ........................15
voriconazole tabs 200mg ..........15
voriconazole tabs 50mg ............15
votrient......................................19
vytorin tabs 10mg, 10mg, 10mg, 20mg,
10mg, 40mg..........................33
vytorin tabs 10mg, 80mg ..........33
W
warfarin sodium........................28
welchol .....................................27
X
xalkori.......................................19
xarelto tabs 10mg......................28
xarelto tabs 15mg, 20mg ..........28
xeljanz.......................................48
xenazine....................................36
xeomin ......................................22
xgeva.........................................50
xifaxan tabs 200mg.....................6
xifaxan tabs 550mg.....................6
xolair.........................................55
xopenex hfa ..............................55
xtandi ........................................18
xyrem........................................56
Y
yervoy .......................................17
yf-vax........................................49
Z
zaleplon.....................................56
zaltrap inj 100mg/4ml...............17
zavesca......................................38
zazole crea ................................15
zelapar.......................................20
zelboraf .....................................17
zemaira .....................................55
zemplar caps 1mcg, 2mcg ........50
zemplar inj 2mcg/ml.................50
zenchent fe................................46
zenpep.......................................38
zeosa .........................................46
zerit solr ....................................23
zetia...........................................34
ziagen........................................23
zidovudine ................................23
ziprasidone hcl..........................21
zirgan ........................................22
zithromax pack ...........................8
zolinza.......................................15
zolpidem tartrate.......................56
zolpidem tartrate er...................56
zometa inj 4mg/5ml ..................50
zomig soln ................................16
zomig tabs.................................16
zomig zmt .................................16
zonalon .....................................38
zonisamide..................................9
zortress tabs 0.5mg, 0.75mg .....48
zostavax ....................................49
zovia 1/35e................................46
zovia 1/50e................................46
zovirax crea ..............................24
zovirax oint...............................24
zyclara.......................................38
zyflo cr......................................53
zylet ..........................................51
zymaxid ......................................8
zytiga ........................................47
zyvox inj .....................................6
zyvox susr...................................6
zyvox tabs...................................6
zafirlukast .................................53
73