Simply Healthcare Plans, Inc
Simply Healthcare Plans, Inc
Simply Healthcare Plans, Inc
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Drug Name Tier Notes<br />
ANTIPARASITICS<br />
Anthelmintics<br />
ALBENZA 3<br />
mebendazole 2<br />
STROMECTOL 4<br />
Antiprotozoals<br />
chloroquine phosphate 2<br />
DARAPRIM 4<br />
hydroxychloroquine sulfate 2<br />
LACRISERT 4<br />
MALARONE 4<br />
mefloquine hcl 2<br />
MEPRON 5<br />
NEBUPENT 4 QL 6/28 BD<br />
PENTAM 4 BD<br />
PLAQUENIL 4<br />
Pediculicides/ Scabicides<br />
acticin 1 GC<br />
EURAX 4<br />
lindane 2<br />
malathion 2<br />
OVIDE 4<br />
permethrin 2<br />
ANTIPARKINSON AGENTS<br />
Antiparkinson Agents<br />
amantadine 2<br />
APOKYN 5 QL 90 SP<br />
AZILECT 3 QL 30<br />
benztropine mesylate 1 GC<br />
bromocriptine mesylate 2<br />
carbidopa/levodopa 2<br />
COMTAN 3 QL 240<br />
MIRAPEX 4<br />
MIRAPEX ER 4 PA<br />
PARCOPA 4<br />
PARLODEL 4 PA<br />
pramipexole 2<br />
ropinirole hcl 2<br />
selegiline hcl 2<br />
SINEMET 4<br />
SINEMET CR 4 PA<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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