Simply Healthcare Plans, Inc

Drug Name Tier Notes
TEGRETOL 4
VIMPAT INJ, ORAL SOL 4 QL 1200
VIMPAT TAB 4 QL 60
Sodium Channel Inhibitors
BANZEL SUSP 4
ANTIDEMENTIA AGENTS
Cholinesterase Inhibitors
ARICEPT 4
donepezil 2
EXELON 3 QL 31/31
galantamine 12 mg tab 2 QL 62/31
galantamine 4 mg tab 2
galantamine 8 mg tab 2 QL 30
galantamine er cap 2 QL 31/31
RAZADYNE 4 PA QL 180
Glutamate Pathway Modifiers
NAMENDA SOL 3 QL 360
NAMENDA TAB 3 QL 60
ANTIDEPRESSANTS
Antidepressants, Other
ABILIFY DISCMELT 4 PA
ABILIFY INJ 4 PA QL 120
ABILIFY SOL 4 PA
ABILIFY TAB 4 PA QL 30
APLENZIN 4 QL 30 ST
budeprion 2
bupropion 2
bupropion sr 100 mg tab 2
bupropion sr 150 mg tab 2 QL 62/31
bupropion sr 200 mg tab 2 QL 60
maprotiline hcl 2
mirtazapine 2
nefazodone hcl 1 GC
OLEPTRO 4
paroxetine er 12.5 mg tab 2 QL 180
SEROQUEL XR 3 QL 60
SYMBYAX 4 QL 30
trazodone hcl 1 GC
Monoamine Oxidase Inhibitors
EMSAM 4 QL 31/31
MARPLAN 4
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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