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