Additional Drug Coverage Additional prescription drug coverage Your plan includes extra coverage for certain drugs and supplies as shown below. This is not a complete list of prescription drugs and supplies covered by our plan. For a complete list, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday. Lower-cost Medicare prescription drugs and supplies Your plan covers some of your Medicare prescription drugs and supplies at a lower drug copay than in your drug list (formulary). The amount you pay for these prescription drugs and supplies does apply to your Medicare prescription drug out-of-pocket costs. Payments for these prescription drugs (made by you or the plan) are treated the same as payments made for drugs in your plan’s drug list (formulary). 1 These drugs and supplies are part of your Medicare prescription drug coverage. 1 Birth Control All contraceptive medications and devices Blood Glucose Meters, Test Strips and Lancets ACCU-CHEK® Aviva Plus Test Strips ACCU-CHEK® Guide Meter & Test Strip ACCU-CHEK® Guide Me Meter & Test Strip ACCU-CHEK® SmartView Test Strips Lancets Lancing devices OneTouch Ultra® Test Strips OneTouch Verio® Flex™ Meter & Test Strips OneTouch Verio® Reflect™ Meter & Test Strips Diabetes drugs and supplies Acarbose Tablet Actoplus Met (XR) Tablet Actos Tablet Adlyxin Injection Admelog Injection Afrezza Inhalation Powder Alcohol Swabs Alogliptin Tablet Alogliptin/Metformin Tablet Alogliptin/Pioglitazone Tablet Amaryl Tablet Apidra Injection Avandia Tablet Baqsimi Nasal Powder Basaglar Injection Bydureon Injection Byetta Injection Cycloset Tablet Diazoxide Suspension Duetact Tablet Farxiga Tablet Fiasp Injection Gauze Pads 2"X2" Glimepiride Tablet Glipizide (ER & XL) Tablet Glipizide/Metformin Tablet Glucagen Hypokit Glucagon Emergency Kit Glucophage (XR) Tablet Y0066_200527_081500_C
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Additional Drug Coverage
Additional prescription drug coverage
Your plan includes extra coverage for certain drugs and supplies as shown below.
This is not a complete list of prescription drugs and supplies covered by our plan. For a complete
list, please call Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time,
Monday – Friday.
Lower-cost Medicare prescription drugs and supplies
Your plan covers some of your Medicare prescription drugs and supplies at a lower drug copay
than in your drug list (formulary).
The amount you pay for these prescription drugs and supplies does apply to your Medicare
prescription drug out-of-pocket costs. Payments for these prescription drugs (made by you or the
plan) are treated the same as payments made for drugs in your plan’s drug list (formulary).1
These drugs and supplies are part of your Medicare prescription drug coverage.1
Birth Control
All contraceptive medications and devices
Blood Glucose Meters, Test Strips and
Lancets
ACCU-CHEK® Aviva Plus Test Strips
ACCU-CHEK® Guide Meter & Test Strip
ACCU-CHEK® Guide Me Meter & Test Strip
ACCU-CHEK® SmartView Test Strips
Lancets
Lancing devices
OneTouch Ultra® Test Strips
OneTouch Verio® Flex™ Meter & Test Strips
OneTouch Verio® Reflect™ Meter & Test Strips
Diabetes drugs and supplies
Acarbose Tablet
Actoplus Met (XR) Tablet
Actos Tablet
Adlyxin Injection
Admelog Injection
Afrezza Inhalation Powder
Alcohol Swabs
Alogliptin Tablet
Alogliptin/Metformin Tablet
Alogliptin/Pioglitazone Tablet
Amaryl Tablet
Apidra Injection
Avandia Tablet
Baqsimi Nasal Powder
Basaglar Injection
Bydureon Injection
Byetta Injection
Cycloset Tablet
Diazoxide Suspension
Duetact Tablet
Farxiga Tablet
Fiasp Injection
Gauze Pads 2"X2"
Glimepiride Tablet
Glipizide (ER & XL) Tablet
Glipizide/Metformin Tablet
Glucagen Hypokit
Glucagon Emergency Kit
Glucophage (XR) Tablet
Y0066_200527_081500_C
Glucotrol (XL) Tablet
Glyburide (Micronized) Tablet
Glyburide/Metformin Tablet
Glynase Tablet
Glyset Tablet
Glyxambi Tablet
Gvoke Injection
Humalog Injection
Humulin Injection
InPen Insulin Pen
Insulin Syringes
Invokamet (XR) Tablet
Invokana Tablet
Janumet (XR) Tablet
Januvia Tablet
Jardiance Tablet
Jentadueto (XR) Tablet
Kazano Tablet
Kombiglyze XR Tablet
Korlym Tablet
Lantus Injection
Levemir Injection
Metformin (ER) Tablet
Miglitol Tablet
Myxredlin
Nateglinide Tablet
Nesina Tablet
Novolin Injection
Novolog Injection
Omnipod System
Onglyza Tablet
Oseni Tablet
Ozempic Injection
Pen Needles
Pioglitazone Tablet
Pioglitazone/Glimepiride Tablet
Pioglitazone/Metformin Tablet
Prandin Tablet
Precose Tablet
Proglycem Suspension
Qtern Tablet
Repaglinide Tablet
Riomet Solution
Rybelsus Tablet
Segluromet Tablet
Soliqua Injection
Starlix Tablet
Steglatro Tablet
Steglujan Tablet
Symlinpen Injection
Synjardy (XR) Tablet
Tolbutamide Tablet
Toujeo Injection
Tradjenta Tablet
Tresiba Injection
Trijardy XR Tablet
Trulicity Injection
V-Go Device
Victoza Injection
Xigduo XR Tablet
Xultophy Injection
Tobacco Cessation
Bupropion 150 SR Tablet
Chantix Tablet
Nicotrol Inhaler
Nicotrol Nasal Spray
Zyban 150mg SR Tablet
Vaccines
All vaccines
Bold type = Brand name drug Plain type = Generic drug
The drugs listed below to treat asthma or COPD, heart disease/heart failure, hypertension and
cholesterol are available at a reduced copay. See your Evidence of Coverage for information about
copays.
Asthma or Chronic Obstructive Pulmonary
Disease (COPD)
Accolate Tablets
Advair Diskus & HFA
Airduo Respiclick
Albuterol Inhalation, Syrup and (ER) Tablet
Alvesco Inhaler
Aminophylline Injection
Anoro Ellipta
Arcapta Neohaler
Arnuity Ellipta
Asmanex HFA & Twisthaler
Atrovent HFA
Bevespi Aerosphere
Breo Ellipta
Brovana Inhalation
Budesonide Inhalation
Cinqair Injection
Combivent Respimat
Cromolyn Inhalation
Daliresp Tablet
Duaklir Inhaler
Dulera Inhaler
Dupixent Injection
Elixophyllin Elixir
Fasenra Injection
Flovent Diskus & HFA
Fluticasone Propionate/Salmeterol Diskus &
HFA
Incruse Ellipta
Ipratropium Bromide Inhalation
Ipratropium Bromide/Albuterol Inhalation
Levalbuterol Inhalation
Levalbuterol Tartrate HFA
Lonhala Magnair Solution
Metaproterenol Syrup & Tablet
Montelukast Granules & (Chewable) Tablet
Nucala Injection
Perforomist Inhalation
Proair HFA & Respiclick
Proventil HFA
Pulmicort Flexhaler & Inhalation
Qvar Inhaler & RediHaler
Seebri Neohaler
Serevent Diskus
Singulair Granules & (Chewable) Tablets
Spiriva Handihaler & Respimat
Stiolto Respimat
Striverdi Respimat
Symbicort Inhaler
Terbutaline Injection & Tablet
Theo-24 CR & ER Capsule
Theophylline Injection, Oral Solution, CR & ER
Tablet
Trelegy Ellipta
Tudorza Pressair
Utibron Neohaler
Ventolin HFA
Wixela Inhub
Xolair Injection
Xopenex HFA & Inhalation
Yupelri Inhalation
Zafirlukast Tablet
Zileuton ER Tablet
Zyflo (CR) Tablet
Hyperlipidemia (high cholesterol)
Altoprev ER Tablet
Antara Capsule
Atorvastatin Tablet
Cholestyramine (Light) Powder
Colesevelam Tablet
Colestid Granules & Tablet
Colestipol Granules & Tablet
Crestor Tablet
Ezallor Sprinkle Capsule
Ezetimibe Tablet
Ezetimibe/Simvastatin Tablet
Fenofibrate Tablet & Capsule
Fenofibric Acid DR Capsule & Tablet
Fenoglide Tablet
Fibricor Tablet
Flolipid Suspension
Fluvastatin Capsule & ER Tablet
Gemfibrozil Tablet
Juxtapid Capsule
Lescol XL Tablet
Lipitor Tablet
Lipofen Capsule
Livalo Tablet
Lopid Tablet
Lovastatin Tablet
Lovaza Capsule
Nexletol Tablet
Nexlizet Tablet
Niacin (ER) Tablet
Niacor Tablet
Niaspan ER Tablet
Omega-3-Acid Ethyl Esters Capsule
Praluent Injection
Pravachol Tablet
Pravastatin Tablet
Prevalite Powder
Questran (Light) Powder
Repatha Injection
Rosuvastatin Tablet
Simvastatin Tablet
Tricor Tablet
Triglide Tablet
Trilipix Capsule
Vascepa Capsule
Vytorin Tablet
Welchol Packet and Tablet
Zetia Tablet
Zocor Tablet
Zypitamag Tablet
Heart Disease or Heart Failure
Acetazolamide ER Capsule, Injection and Tablet
Aldactazide Tablet
Aldactone Tablet
Amiloride Tablet
Amiloride/Hydrochlorothiazide Tablet
Amlodipine/Atorvastatin Tablet
Betapace (AF) Tablet
Bidil Tablet
Bumetanide Injection & Tablet
Bumex Tablet
Caduet Tablet
Carospir Suspension
Chlorothiazide Injection & Tablet
Chlorthalidone Tablet
Corlanor Tablet
Digitek Tablet
Digox Tablet
Digoxin Injection, Oral Solution & Tablet
Diuril Suspension
Dyazide Capsule
Dyrenium Capsule
Edecrin Tablet
Eplerenone Tablet
Ethacrynate Sodium Injection
Ethacrynic Acid Tablet
Furosemide Injection, Oral Solution & Tablet
Hydrochlorothiazide Capsule & Tablet
Indapamide Tablet
Inspra Tablet
Isoproterenol Injection
Isuprel Injection
Lanoxin Injection & Tablet
Lasix Tablet
Mannitol Injection
Maxzide Tablet
Methazolamide
Metolazone Tablet
Osmitrol Injection
Sodium Diuril Injection
Sodium Edecrin Injection
Sorine Tablet
Sotalol Injection & (AF) Tablet
Sotylize Solution
Spironolactone Tablet
Spironolactone/Hydrochlorothiazide Tablet
Torsemide Tablet
Triamterene/Hydrochlorothiazide Capsule &
Tablet
Hypertension (high blood pressure)
Accupril Tablet
Accuretic Tablet
Acebutolol Capsule
Aliskiren Tablet
Altace Capsule
Amlodipine Tablet
Amlodipine/Benazepril Capsule
Amlodipine/Olmesartan Tablet
Amlodipine/Valsartan Tablet
Amlodipine/Valsartan/Hydrochlorothiazide
Tablet
Atacand (HCT) Tablet
Atenolol Tablet
Atenolol/Chlorthalidone Tablet
Avalide Tablet
Avapro Tablet
Azor Tablet
Benazepril Tablet
Benazepril/Hydrochlorothiazide Tablet
Benicar (HCT) Tablet
Betaxolol Tablet
Bisoprolol Tablet
Bisoprolol/Hydrochlorothiazide Tablet
Brevibloc Injection & IV Solution
Bystolic Tablet
Calan (SR) Tablet
Candesartan Tablet
Candesartan/Hydrochlorothiazide Tablet
Captopril Tablet
Captopril/Hydrochlorothiazide Tablet
Cardene IV Solution
Cardizem (LA) Tablet & CD Capsule
Cardura Tablet
Cartia XT Capsule
Carvedilol ER Capsule & Tablet
Catapres Tablet & TTS Patch
Cleviprex IV Emulsion
Clonidine Tablet & Patch
Coreg CR Capsule & Tablet
Corgard Tablet
Corlopam Injection
Cozaar Tablet
Diltiazem CD & ER Capsule, Injection, & (ER)
Tablet
Dilt-XR Capsule
Diovan (HCT) Tablet
Doxazosin Tablet
Dutoprol Tablet
Edarbi Tablet
Edarbyclor Tablet
Enalapril Tablet
Enalapril/Hydrochlorothiazide Tablet
Enalaprilat Injection
Entresto Tablet
Epaned Solution
Esmolol Injection
Exforge (HCT) Tablet
Felodipine ER Tablet
Fosinopril Tablet
Fosinopril/Hydrochlorothiazide Tablet
Guanfacine Tablet
Hemangeol Oral Solution
Hydralazine Injection & Tablet
Hyzaar Tablet
Inderal LA and XL Capsule
Innopran XL Capsule
Irbesartan Tablet
Irbesartan/Hydrochlorothiazide Tablet
Isradipine Capsule
Kapspargo Capsule
Katerzia Suspension
Labetalol Tablet & Injection
Lisinopril Tablet
Lisinopril/Hydrochlorothiazide Tablet
Lopressor (HCT) Tablet
Losartan Tablet
Losartan/Hydrochlorothiazide Tablet
Lotensin (HCT) Tablet
Lotrel Capsule
Matzim LA Tablet
Methyldopa Tablet
Methyldopa/Hydrochlorothiazide Tablet
Metoprolol Succinate ER Tablet
Metoprolol Tartrate Injection & (HCT) Tablet
Metoprolol/Hydrochlorothiazide Tablet
Micardis (HCT) Tablet
Minipress Capsule
Minoxidil Tablet
Moexipril Tablet
Nadolol Tablet
Nadolol/Bendroflumethiazide Tablet
Nicardipine Capsule & Injection
Nifedipine Capsule & ER Tablet
Nimodipine Capsule
Nisoldipine ER Tablet
Nitropress Injection
Norvasc Tablet
Olmesartan Tablet
Olmesartan/Amlodipine/Hydrochlorothiazide
Tablet
Olmesartan/Hydrochlorothiazide Tablet
Perindopril Tablet
Pindolol Tablet
Prazosin Capsule
Prinivil Tablet
Procardia Capsule & XL Tablet
Propranolol ER Capsule, Injection, Oral Solution
& Tablet
Propranolol/Hydrochlorothiazide Tablet
Qbrelis Oral Solution
Quinapril Tablet
Quinapril/Hydrochlorothiazide Tablet
Ramipril Capsule
Sodium Nitroprusside Injection
Sular Tablet
Tarka CR Tablet
Taztia XT Capsule
Tekturna Tablet
Tekturna (HCT) Tablet
Telmisartan Tablet
Telmisartan/Amlodipine Tablet
Telmisartan/Hydrochlorothiazide Tablet
Tenoretic Tablet
Tenormin Tablet
Terazosin Capsule
Tiazac Capsule
Timolol Maleate Tablet
Toprol XL Tablet
Trandolapril Tablet
Trandolapril/Verapamil ER Tablet
Tribenzor Tablet
Twynsta Tablet
Valsartan Tablet
Valsartan/Hydrochlorothiazide Tablet
Vaseretic Tablet
Vasotec Tablet
Vecamyl Tablet
Verapamil ER & SR Capsule, Injection & (ER)
Tablet
Verelan (PM) Capsule
Zestoretic Tablet
Zestril Tablet
Ziac Tablet
Bold type = Brand name drug Plain type = Generic drug
Lower-cost non-Medicare prescription drugs and supplies
These prescription drugs and supplies are covered in addition to the drugs in your plan’s drug list
(formulary).2
Your plan covers these prescription drugs at a $0 copay.
Drug Name
Cholera Vaccine
Nicotine Gum
Nicotine Lozenges
Nicotine Patches
Oral Typhoid Vaccine
1Information about the appeals and grievance process for these prescription drugs and supplies
can be found in your Evidence of Coverage.
2This non-Medicare drug coverage is in addition to your Medicare drug coverage. Unlike your Medicare drug coverage,
you cannot file a Medicare appeal or grievance for non-Medicare drug coverage. If you have questions, please call
Customer Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday.
Bonus Drug List
The Plan offers a bonus drug list. The prescription drugs on this list are covered in addition to the
drugs on the plan’s drug list (formulary).
The drug tier for each prescription drug is shown on the list.
Although you pay the same copay for these drugs as shown in the Summary of Benefits and
Evidence of Coverage, the amount you pay for these additional prescription drugs does not apply
to your Medicare Part D out-of-pocket costs. Payments for these additional prescription drugs
(made by you or the plan) are treated differently from payments made for other prescription drugs.
Coverage for the prescription drugs on the bonus drug list is in addition to your Part D drug
coverage. Unlike your Part D drug coverage, you are unable to file a Medicare appeal or grievance
for drugs on the bonus drug list. If you have questions, please call Customer Service toll-free at
1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday.
If you get Extra Help from Medicare to pay for your prescription drugs, it will not apply to the drugs
on this bonus drug list.
This is not a complete list of the prescription drugs available to you or the restrictions and
limitations that may apply through the bonus drug list. If your drug has any coverage rules or limits,
there will be code(s) in the “Coverage Rules or Limits on use” column of the chart. The codes and
what they mean are shown below. If you have questions about drug coverage, please call Customer
Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday.
QL - Quantity limits
The plan only covers a certain amount of this drug for one copay or over a certain number of days.
These limits may be in place to ensure safe and effective use of the drug.
MME - Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is
designed to monitor safe dosing levels of opioids for individuals who may be taking more than one
opioid drug for pain management. If your doctor prescribes more than this amount or thinks the
limit is not right for your situation, you or your doctor can ask the plan to cover the additional
quantity.
7D - 7-Day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members
with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For
members who are new to the plan, and have a recent history of using opioids, the limit may be
overridden by having the pharmacy contact the plan.
DL - Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a one-month supply per prescription.
Y0066_200527_081500_C
Drug NameDrug
TierCoverage Rules or Limits on use
Analgesics - drugs to treat pain, inflammation, and muscle and joint conditions
Inflammation
Salsalate 1
Urinary Tract Pain
Phenazopyridine 1
Anticoagulants - drugs to prevent clotting
Heparin Lock Flush 1
Dermatological agents - drugs to treat skin conditions
Dry, Itchy Scalp
Sulfacetamide Sodium Liquid Wash 10% 1
Sulfacetamide Sodium w/Sulfur in Urea
Emulsion 10-5%1
Dry Skin
Urea 40% Cream 1
Fungal Infections
Iodoquinol-HC Cream 1% 1
Gastrointestinal agents - drugs to treat bowel, intestine and stomach conditions
Irritable Bowel or Ulcers
Clidinium & Chlordiazepoxide 1
Hyoscyamine Sulfate 1
Levbid 3
Hemorrhoids
Hydrocortisone Acetate Suppository 25mg 1
Lidocaine/Hydrocortisone Acetate 1
Genitourinary agents - drugs to treat bladder, genital and kidney conditions
Erectile Dysfunction
Bold type = Brand name drug Plain type = Generic drug
Drug NameDrug
TierCoverage Rules or Limits on use
Edex 4QL (maximum of 20 cartridges per
75 days)
Sildenafil (25 mg, 50 mg, 100 mg) 1QL (maximum of 20 tablets per 75
