Simply Healthcare Plans, Inc
Simply Healthcare Plans, Inc
Simply Healthcare Plans, Inc
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Drug Name Tier Notes<br />
gentamicin 1 GC<br />
gentamicin/nacl 100 mg 1 GC<br />
gentamicin/nacl 60, 80 mg 2<br />
gentasol 1 GC<br />
kanamycin sulfate 1 GC<br />
neomycin sulfate 2<br />
paromomycin 2<br />
tobramycin inj 2<br />
tobramycin sulfate 1 GC<br />
tobrasol 1 GC<br />
Antibacterials, Other<br />
acetic acid 2<br />
baciim 2<br />
bacitracin 1 GC<br />
CHANTIX 0.5 MG 4 QL 11<br />
clindamycin hcl 2<br />
clindamycin phosphate 2<br />
colistimethate sodium 2 BD<br />
FLAGYL 4<br />
HIPREX 4<br />
LINCOCIN 4<br />
MACROBID 4<br />
MACRODANTIN 4<br />
methenamine hippurate 2<br />
METROCREAM 4<br />
METROGEL 4<br />
METROLOTION 4<br />
metronidazole cap, tab 1 GC<br />
metronidazole crm 2<br />
mupirocin 2<br />
nitrofurantoin 2<br />
nitrofurantoin macrocrystal 2<br />
nitrofurantoin monohydrate 2<br />
NORITATE 4<br />
trimethoprim 1 GC<br />
VANCOCIN HCL CAP 5<br />
VANCOCIN HCL INJ 3 BD<br />
vancomycin hcl 2 BD<br />
vandazole 2<br />
ZYVOX 5<br />
Beta-lactam, Cephalosporins<br />
SP-This prescription may be available only at certain pharmacies. For more information consult your Pharmacy<br />
Directory or call Member Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD<br />
users should call 711 Telecommu-nication Relay Services; E-This prescription drug is not normally covered in a<br />
Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count<br />
towards your to-tal drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In<br />
addi-tion, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this<br />
drug.; GC-We provide additional coverage of this prescription drug in the coverage gap. Please refer to our<br />
Evidence of Coverage for more information about this coverage.<br />
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