Simply Healthcare Plans, Inc

Drug Name Tier Notes
gentamicin 1 GC
gentamicin/nacl 100 mg 1 GC
gentamicin/nacl 60, 80 mg 2
gentasol 1 GC
kanamycin sulfate 1 GC
neomycin sulfate 2
paromomycin 2
tobramycin inj 2
tobramycin sulfate 1 GC
tobrasol 1 GC
Antibacterials, Other
acetic acid 2
baciim 2
bacitracin 1 GC
CHANTIX 0.5 MG 4 QL 11
clindamycin hcl 2
clindamycin phosphate 2
colistimethate sodium 2 BD
FLAGYL 4
HIPREX 4
LINCOCIN 4
MACROBID 4
MACRODANTIN 4
methenamine hippurate 2
METROCREAM 4
METROGEL 4
METROLOTION 4
metronidazole cap, tab 1 GC
metronidazole crm 2
mupirocin 2
nitrofurantoin 2
nitrofurantoin macrocrystal 2
nitrofurantoin monohydrate 2
NORITATE 4
trimethoprim 1 GC
VANCOCIN HCL CAP 5
VANCOCIN HCL INJ 3 BD
vancomycin hcl 2 BD
vandazole 2
ZYVOX 5
Beta-lactam, Cephalosporins
SP-This prescription may be available only at certain pharmacies. For more information consult your 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 Telecommu-nication Relay Services; E-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 to-tal drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In
addi-tion, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this
drug.; GC-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.
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