2009 Medicare Part D Plan Formulary Information |
MedicareBlue Rx Option 1 (S5743-001-0)
Benefit Details
|
The MedicareBlue Rx Option 1 (S5743-001-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
|
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 |
SANCTURA 20MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | Q:60 /30Days |
SANCTURA XR 60MG CAPSULE SR 24 HR |
3 |
Level 3: Covered Brand |
50% | 50% | Q:30 /30Days |
SANDOSTATIN LAR 10MG KIT |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SANDOSTATIN LAR 20MG KIT |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SANDOSTATIN LAR 30MG KIT |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SELZENTRY 150MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SELZENTRY 300MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SENSIPAR 30MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SENSIPAR 60MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SENSIPAR 90MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SEREVENT DIS AER 50MCG |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:60 /30Days |
SEROQUEL 100MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:90 /30Days |
SEROQUEL 200MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:90 /30Days |
SEROQUEL 25MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:90 /30Days |
SEROQUEL 300MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:60 /30Days |
SEROQUEL 400MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:60 /30Days |
SEROQUEL 50MG TABLET (100 CT) |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:90 /30Days |
SEROQUEL XR 200MG TABLET SR 24HR |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:30 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL XR 400MG TABLET SR 24HR |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:60 /30Days |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SERTRALINE HCL 20MG/ML CONCENTRATE ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SERTRALINE HCL 20MG/ML CONCENTRATE ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SERTRALINE HCL 25MG TABLET (30 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SIMULECT 10MG VIAL |
4 |
Covered Specialty |
25% | 25% | P |
SIMULECT 20MG VIAL |
4 |
Covered Specialty |
25% | 25% | P |
SIMVASTATIN 10MG TABLET (30 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:45 /30Days |
SIMVASTATIN 20MG TABLET 10000 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:45 /30Days |
SIMVASTATIN 5MG TABLET (90 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:45 /30Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:30 /30Days |
SINGULAIR 10MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | S |
SINGULAIR 4MG GRANULES |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SINGULAIR 4MG TABLET CHEW |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SINGULAIR 5MG TABLET CHEW |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SODIUM CHLORIDE 0.9% IRRIG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SODIUM FLUORIDE 1MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SODIUM POLYSTYRENE SULFONATE POWDER |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM POLYSTYRENE SULFONATE 15G/60ML SUSPENSION ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SODIUM POLYSTYRENE SULFONATE 50G/200ML ENEMA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOLARAZE 3% GEL |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SOLIA 0.15-0.03 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOLTAMOX 10MG/5ML SOLUTION |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SOMAVERT 10MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
SOMAVERT 15MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
SOMAVERT 20MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
SORIATANE 25MG |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SORIATANE CK 25MG KIT |
3 |
Level 3: Covered Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE 120MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SORINE 160MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SORINE 240MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SORINE 80MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL 120MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL 80MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL 80MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTALOL HCL TABLET 240MG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTRET 10MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTRET 20MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTRET 30MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SOTRET 40MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:30 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPRYCEL 20MG TABLET |
4 |
Covered Specialty |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 50MG TABLET |
4 |
Covered Specialty |
25% | 25% | None |
SPRYCEL 70MG TABLET |
4 |
Covered Specialty |
25% | 25% | None |
SPRYCEL TABLETS |
4 |
Covered Specialty |
25% | 25% | None |
SPS 15GM/60ML SUSPENSION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SPS 30GM/120ML ENEMA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SRONYX 0.1-0.02 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SSD 1% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SSD AF 1% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STAGESIC 5MG-500MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STALEVO 100 TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STALEVO 125/200 MG/MG TABLETS |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STALEVO 150 TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STALEVO 18.75/75 MG/MG TABLETS |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STALEVO 200 50-200-200 TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STALEVO 50 TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STARLIX 120MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STARLIX 60MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STERILE GAUZE PADS 2X 2 |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STERILE WATER FOR IRRIGATION 100 24 X 500ML BAG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
STIMATE 1.5MG/ML NASAL SPRAY |
3 |
Level 3: Covered Brand |
50% | 50% | None |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
STROMECTOL 3MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
STROMECTOL 6MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SUBOXONE 2MG-0.5MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SUBOXONE 8MG-2MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SUBUTEX 2MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SUBUTEX 8MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SUCRAID 8500UNITS/ML SOLUTION |
4 |
Covered Specialty |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUCRALFATE 1GM TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULAR 17MG TABLET SR 24HR |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SULAR 25.5MG TABLET SR 24HR |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SULAR 34MG TABLET SR 24HR |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SULAR 8.5MG TABLET SR 24HR |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SULF-10 OPHTHALMIC SOLUTION 10% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFACETAMIDE SODIUM 10% DROPS |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFADIAZINE 500MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFAMETHOXAZOLE/TMP DS TAB |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFASALAZINE 500MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFASALAZINE DR 500MG TABLET DELAYED RELEASE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFATRIM PEDIATRIC SUSP |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFAZINE 500MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 200MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
SUMATRIPTAN |
1 |
Level 1: Covered Generic |
10% | 10% | Q:6 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Level 1: Covered Generic |
10% | 10% | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
1 |
Level 1: Covered Generic |
10% | 10% | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
1 |
Level 1: Covered Generic |
10% | 10% | Q:18 /30Days |
SUPRAX CFIXIME TABLETS USP 400MG 50 TABS BOT |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SURMONTIL 100MG CAPSULE |
3 |
Level 3: Covered Brand |
50% | 50% | None |
SUSTIVA 100MG CAPSULE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SUSTIVA 200MG CAPSULE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SUSTIVA 50MG CAPSULE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SUSTIVA 600MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 12.5MG CAPSULE |
4 |
Covered Specialty |
25% | 25% | None |
SUTENT 25MG CAPSULE |
4 |
Covered Specialty |
25% | 25% | None |
SUTENT 50MG CAPSULE |
4 |
Covered Specialty |
25% | 25% | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:10 /30Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:10 /30Days |
SYMLIN 0.6MG/ML VIAL |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
SYNAGIS 100MG/1ML VIAL |
4 |
Covered Specialty |
25% | 25% | None |
SYNAGIS 50MG/0.5ML VIAL |
4 |
Covered Specialty |
25% | 25% | None |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Covered Specialty |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNERCID 500MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
SYPRINE 250MG CAPSULE (100 CT) |
3 |
Level 3: Covered Brand |
50% | 50% | None |