2009 Medicare Part D Plan Formulary Information |
PriorityMedicareRx (S5857-001-0)
Benefit Details
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The PriorityMedicareRx (S5857-001-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 13 which includes: MI
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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 |
SELEGILINE HCL 5MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SELEGILINE HCL 5MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SELSUN RX 2.5% SHAMPOO |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SELZENTRY 150MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
SELZENTRY 300MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
SEMPREX-D 60/8 CAPSULE |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
SENSIPAR 30MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SENSIPAR 60MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SENSIPAR 90MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROMYCIN 250MG PULVULE |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
SEROQUEL 100MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL 200MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL 25MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL 300MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL 400MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL 50MG TABLET (100 CT) |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL XR 200MG TABLET SR 24HR |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROQUEL XR 400MG TABLET SR 24HR |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SEROSTIM 4MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROSTIM 5MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
SEROSTIM 6MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SERTRALINE HCL 20MG/ML CONCENTRATE ORAL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SERTRALINE HCL 25MG TABLET (30 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SIMCOR 1000-20MG TABLET MULTIPHASIC RELEASE 24HR |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SIMVASTATIN 10MG TABLET (30 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 20MG TABLET 10000 BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SIMVASTATIN 5MG TABLET (90 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SINGULAIR 10MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SINGULAIR 4MG GRANULES |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SINGULAIR 5MG TABLET CHEW |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SKELAXIN 800MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SODIUM POLYSTYRENE SULFONATE POWDER |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLARAZE 3% GEL |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SOLTAMOX 10MG/5ML SOLUTION |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SOMAVERT 10MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
SOMAVERT 15MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
SOMAVERT 20MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
SORIATANE 25MG |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
SORIATANE CK 25MG KIT |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
SORINE 160MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTALOL HCL 120MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTALOL HCL 80MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTALOL HCL 80MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTALOL HCL TABLET 240MG |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTRET 10MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTRET 20MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTRET 30MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SOTRET 40MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SPIRONOLACTONE 100MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SPRYCEL 20MG TABLET |
4 |
Specialty Tier |
33% | N/A | S |
SPRYCEL 50MG TABLET |
4 |
Specialty Tier |
33% | N/A | S |
SPRYCEL 70MG TABLET |
4 |
Specialty Tier |
33% | N/A | S |
SPS 15GM/60ML SUSPENSION |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
STAGESIC 5MG-500MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
STARLIX 120MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
STARLIX 60MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
STERILE GAUZE PADS 2X 2 |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
STRATTERA 100MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STRATTERA 10MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STRATTERA 18MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STRATTERA 25MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STRATTERA 40MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STRATTERA 60MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STRATTERA 80MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STROMECTOL 3MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
STROMECTOL 6MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUBOXONE 2MG-0.5MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUBOXONE 8MG-2MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUBUTEX 2MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUBUTEX 8MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUCRAID 8500UNITS/ML SOLUTION |
4 |
Specialty Tier |
33% | N/A | None |
SUCRALFATE 1GM TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFACETAMIDE 10% EYE OINT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFADIAZINE 500MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | 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 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFAMETHOXAZOLE/TMP DS TAB |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFAMYLON 50G PACKET |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
3 |
Non-Preferred Brand |
$65.00 | $162.50 | None |
SULFASALAZINE 500MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFASALAZINE DR 500MG TABLET DELAYED RELEASE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULFATRIM PEDIATRIC SUSP |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 200MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Generic Drugs |
$7.00 | $17.50 | Q:18 /31Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
1 |
Generic Drugs |
$7.00 | $17.50 | Q:18 /31Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
1 |
Generic Drugs |
$7.00 | $17.50 | Q:18 /31Days |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUSTIVA 100MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUSTIVA 200MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUSTIVA 50MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUSTIVA 600MG TABLET |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SUTENT 12.5MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 25MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
SUTENT 50MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMBYAX 12-25MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMBYAX 12-50MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMBYAX 3MG-25MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMBYAX 6-25MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMBYAX 6-50MG CAPSULE |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |
SYMLIN 0.6MG/ML VIAL |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | S |
SYNAGIS 100MG/1ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Specialty Tier |
33% | N/A | None |
SYPRINE 250MG CAPSULE (100 CT) |
2 |
Preferred Brand on Formulary |
$42.00 | $105.00 | None |