2009 Medicare Part D Plan Formulary Information |
Advantage Star Plan by RxAmerica (S5644-087-0)
Benefit Details
|
The Advantage Star Plan by RxAmerica (S5644-087-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 31 which includes: ID UT
|
Drugs Starting with Letter S
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
SAIZEN 5MG VIAL |
3 |
Specialty |
25% | N/A | P |
SAIZEN 8.8MG CLICK.EASY CARTG |
3 |
Specialty |
25% | N/A | P |
SAIZEN 8.8MG INJECTION |
3 |
Specialty |
25% | N/A | P |
SANCTURA 20MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
4 |
Non-Preferred |
45% | 45% | P Q:1 /28Days |
SANDIMMUNE 100MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | P |
SANDIMMUNE 100MG/ML TUBEX |
2 |
Preferred Brand |
25% | 30% | P |
SANDIMMUNE 25MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | P |
SANDIMMUNE 50MG/ML AMPUL |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN 0.05MG/ML AMPUL |
2 |
Preferred Brand |
25% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDOSTATIN 0.1MG/ML AMPUL |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN 0.2MG/ML VIAL |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN 0.5MG/ML AMPUL |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN 1MG/ML VIAL |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN LAR 10MG KIT |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN LAR 20MG KIT |
2 |
Preferred Brand |
25% | 30% | P |
SANDOSTATIN LAR 30MG KIT |
2 |
Preferred Brand |
25% | 30% | P |
SELEGILINE HCL 5MG CAPSULE |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SELEGILINE HCL 5MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SELZENTRY 150MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 300MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SEMPREX-D 60/8 CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
SENSIPAR 30MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SENSIPAR 60MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SENSIPAR 90MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SEREVENT DIS AER 50MCG |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL 100MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL 200MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL 25MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL 300MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL 400MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 50MG TABLET (100 CT) |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL XR 200MG TABLET SR 24HR |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
2 |
Preferred Brand |
25% | 30% | None |
SEROQUEL XR 400MG TABLET SR 24HR |
2 |
Preferred Brand |
25% | 30% | None |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SERTRALINE HCL 20MG/ML CONCENTRATE ORAL |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SERTRALINE HCL 25MG TABLET (30 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SIMULECT 10MG VIAL |
3 |
Specialty |
25% | N/A | P |
SIMULECT 20MG VIAL |
3 |
Specialty |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 10MG TABLET (30 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SIMVASTATIN 20MG TABLET 10000 BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SIMVASTATIN 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SINGULAIR 10MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SINGULAIR 4MG GRANULES |
2 |
Preferred Brand |
25% | 30% | None |
SINGULAIR 4MG TABLET CHEW |
2 |
Preferred Brand |
25% | 30% | None |
SINGULAIR 5MG TABLET CHEW |
2 |
Preferred Brand |
25% | 30% | None |
SODIUM BICARB INJ 7.5% |
4 |
Non-Preferred |
45% | 45% | P |
SODIUM BICARB INJ 8.4% |
4 |
Non-Preferred |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SODIUM CHLORIDE INJECTION 3% 24X500ML BAG |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SODIUM CHLORIDE INJECTION 5% |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SODIUM FLUORIDE 1MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SODIUM POLYSTYRENE SULFONATE POWDER |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SODIUM POLYSTYRENE SULFONATE 15G/60ML SUSPENSION ORAL |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOLARAZE 3% GEL |
2 |
Preferred Brand |
25% | 30% | None |
SOLIA 0.15-0.03 TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOLTAMOX 10MG/5ML SOLUTION |
2 |
Preferred Brand |
25% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLU-CORTEF 100MG ACT-O-VL |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOLU-CORTEF 500MG ACT-O-VL |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOMAVERT 10MG VIAL |
2 |
Preferred Brand |
25% | 30% | P |
SOMAVERT 15MG VIAL |
2 |
Preferred Brand |
25% | 30% | P |
SOMAVERT 20MG VIAL |
2 |
Preferred Brand |
25% | 30% | P |
SORINE 120MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SORINE 160MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SORINE 240MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SORINE 80MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL HCL 80MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SOTRET 10MG CAPSULE |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SOTRET 20MG CAPSULE |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SOTRET 40MG CAPSULE |
1 |
Preferred Generic |
$5.25 | $0.00 | P |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
2 |
Preferred Brand |
25% | 30% | None |
SPIRONOLACTONE 100MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SPORANOX 100MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPORANOX 100MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | P |
SPORANOX 10MG/ML SOLUTION |
2 |
Preferred Brand |
25% | 30% | P |
SPRINTEC 0.25-0.035 TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SPRYCEL 20MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SPRYCEL 50MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SPRYCEL 70MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SPRYCEL TABLETS |
2 |
Preferred Brand |
25% | 30% | None |
SPS 15GM/60ML SUSPENSION |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SPS 30GM/120ML ENEMA |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SSD 1% CREAM |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SSD AF 1% CREAM |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STADOL 2MG/ML VIAL |
2 |
Preferred Brand |
25% | 30% | None |
STAGESIC 5MG-500MG CAPSULE |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
STARLIX 120MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
STARLIX 60MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
STERILE GAUZE PADS 2X 2 |
1 |
Preferred Generic |
$5.25 | $0.00 | Q:100 /30Days |
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
STIMATE 1.5MG/ML NASAL SPRAY |
2 |
Preferred Brand |
25% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBOXONE 2MG-0.5MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SUBOXONE 8MG-2MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SUBUTEX 2MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SUBUTEX 8MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SUCRAID 8500UNITS/ML SOLUTION |
2 |
Preferred Brand |
25% | 30% | P |
SUCRALFATE 1GM TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULF-10 OPHTHALMIC SOLUTION 10% |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFACETAMIDE 10% EYE OINT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFACETAMIDE SODIUM 10% DROPS |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFADIAZINE 500MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFASALAZINE DR 500MG TABLET DELAYED RELEASE |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFATRIM PEDIATRIC SUSP |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFAZINE 500MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 200MG TABLET |
1 |
Preferred Generic |
$5.25 | $0.00 | None |
SUMATRIPTAN |
1 |
Preferred Generic |
$5.25 | $0.00 | Q:4 /30Days |
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD |
1 |
Preferred Generic |
$5.25 | $0.00 | Q:4 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Preferred Generic |
$5.25 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
1 |
Preferred Generic |
$5.25 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
1 |
Preferred Generic |
$5.25 | $0.00 | Q:9 /30Days |
SURMONTIL 100MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
SURMONTIL 25MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
SURMONTIL 50MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
SUSTIVA 100MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
SUSTIVA 200MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 50MG CAPSULE |
2 |
Preferred Brand |
25% | 30% | None |
SUSTIVA 600MG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SUTENT 25MG CAPSULE |
3 |
Specialty |
25% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
2 |
Preferred Brand |
25% | 30% | None |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
2 |
Preferred Brand |
25% | 30% | None |
SYMBYAX 12-25MG CAPSULE |
4 |
Non-Preferred |
45% | 45% | None |
SYMBYAX 12-50MG CAPSULE |
4 |
Non-Preferred |
45% | 45% | None |
SYMBYAX 3MG-25MG CAPSULE |
4 |
Non-Preferred |
45% | 45% | None |
SYMBYAX 6-25MG CAPSULE |
4 |
Non-Preferred |
45% | 45% | None |
SYMBYAX 6-50MG CAPSULE |
4 |
Non-Preferred |
45% | 45% | None |
SYMLIN 0.6MG/ML VIAL |
2 |
Preferred Brand |
25% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNAREL 2MG/ML NASAL SPRAY |
3 |
Specialty |
25% | N/A | P |
SYNTHROID 100MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 112 MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 125MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 137MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 150MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 175MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 200MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 25MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 300MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 50MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 75MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYNTHROID 88 MCG TABLET |
2 |
Preferred Brand |
25% | 30% | None |
SYPRINE 250MG CAPSULE (100 CT) |
2 |
Preferred Brand |
25% | 30% | None |