2009 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Premier (S5810-181-0)
Benefit Details
|
The Aetna Medicare Rx Premier (S5810-181-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 11 which includes: FL
|
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 |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SAIZEN 8.8MG CLICK.EASY CARTG |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SAIZEN 8.8MG INJECTION |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SALAGEN 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SALAGEN 7.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SANCTURA 20MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SANCTURA XR 60MG CAPSULE SR 24 HR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Tier 5 - Specialty |
33% | 33% | P S Q:4 /30Days |
SANDIMMUNE 100MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDIMMUNE 25MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SANDOSTATIN 0.05MG/ML AMPUL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN 0.1MG/ML AMPUL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN 0.2MG/ML VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN 0.5MG/ML AMPUL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN 1MG/ML VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN LAR 10MG KIT |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN LAR 20MG KIT |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SANDOSTATIN LAR 30MG KIT |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SARAFEM 10MG PULVULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SARAFEM 20MG PULVULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:4 /1Days |
SARAFEM TABS |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
SARAFEM TABS |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:4 /1Days |
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SECTRAL 200MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
SECTRAL 400MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
SELEGILINE HCL 5MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SELEGILINE HCL 5MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SELFEMRA CAPSULES 10MG 28 CAPSULE BLPK |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELFEMRA CAPSULES 20MG 28 CAPSULE 4X7 BLPK |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:4 /1Days |
SELSUN RX 2.5% SHAMPOO |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SELZENTRY 150MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SELZENTRY 300MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SEMPREX-D 60/8 CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:4 /1Days |
SENSIPAR 30MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SENSIPAR 60MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SENSIPAR 90MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SEPTRA 80/400 TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SEPTRA DS TABLET 800-160 |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SEREVENT DIS AER 50MCG |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROMYCIN 250MG PULVULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SEROQUEL 100MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:3 /1Days |
SEROQUEL 200MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:4 /1Days |
SEROQUEL 25MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:6 /1Days |
SEROQUEL 300MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
SEROQUEL 400MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
SEROQUEL 50MG TABLET (100 CT) |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:3 /1Days |
SEROQUEL XR 200MG TABLET SR 24HR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
SEROQUEL XR 400MG TABLET SR 24HR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
SEROSTIM 4MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROSTIM 5MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SEROSTIM 6MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:2 /1Days |
SERTRALINE HCL 20MG/ML CONCENTRATE ORAL |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:10 /1Days |
SERTRALINE HCL 20MG/ML CONCENTRATE ORAL |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:10 /1Days |
SERTRALINE HCL 25MG TABLET (30 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SILVADENE 1% CREAM |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SIMCOR 1000-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
SIMULECT 10MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SIMULECT 20MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SIMVASTATIN 10MG TABLET (30 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SIMVASTATIN 20MG TABLET 10000 BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SIMVASTATIN 40MG TABLET (500 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SIMVASTATIN 5MG TABLET (90 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
SINEMET CR 25/100 TABLET SA |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SINEMET CR 50/200 TABLET SA |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SINEMET-10/100 TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SINEMET-25/100 TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SINEMET-25/250 TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SINGULAIR 10MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
SINGULAIR 4MG GRANULES |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
SINGULAIR 4MG TABLET CHEW |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
SINGULAIR 5MG TABLET CHEW |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
SKELAXIN 800MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SKELID 200MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SODIUM BICARB INJ 7.5% |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SODIUM BICARB INJ 8.4% |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.9% IRRIG |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SODIUM CHLORIDE INJECTION 3% 24X500ML BAG |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE INJECTION 5% |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SODIUM FLUORIDE 1MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SODIUM LACTATE 1/6MOLAR INJ |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SODIUM POLYSTYRENE SULFONATE POWDER |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SODIUM POLYSTYRENE SULFONATE 15G/60ML SUSPENSION ORAL |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SODIUM POLYSTYRENE SULFONATE 50G/200ML ENEMA |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOLARAZE 3% GEL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLIA 0.15-0.03 TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOLODYN 135MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SOLODYN 45MG TABLET SR 24HR (100 CT) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SOLODYN 90MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SOLTAMOX 10MG/5ML SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-CORTEF 1000MG ACT-O-VL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-CORTEF 100MG ACT-O-VL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-CORTEF 250MG ACT-O-VL (2ML) VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLU-CORTEF 500MG ACT-O-VL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-MEDROL 1000MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-MEDROL 125MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-MEDROL 2000MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-MEDROL 40MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-MEDROL 500MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOLU-MEDROL 500MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SOMA 250MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P Q:84 /30Days |
SOMA 350MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P Q:84 /30Days |
SOMA COMPOUND TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P Q:240 /30Days |
SOMA COMPOUND W/CODEINE TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMATULINE DEPOT FOR INJECTION 120MG/0.5ML |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SOMAVERT 10MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SOMAVERT 15MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SOMAVERT 20MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SONATA 10MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:2 /1Days |
SONATA 5MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:4 /1Days |
SORIATANE 25MG |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SORIATANE CK 25MG KIT |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SORINE 120MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SORINE 160MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SORINE 240MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE 80MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL 120MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL 120MG TABLET 100 BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL 80MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL 80MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTALOL HCL TABLET 240MG |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SOTRET 10MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
SOTRET 20MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
SOTRET 30MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTRET 40MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
SPECTRACEF 200MG TABLET (60 CT) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SPECTRACEF 400 MG DOSE PACK TB |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SPIRONOLACTONE 100MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SPORANOX 100MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SPORANOX 100MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SPORANOX 10MG/ML SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRINTEC 0.25-0.035 TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SPRYCEL 20MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SPRYCEL 50MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SPRYCEL 70MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SPRYCEL TABLETS |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SPS 15GM/60ML SUSPENSION |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SPS 30GM/120ML ENEMA |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SRONYX 0.1-0.02 TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SSD 1% CREAM |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SSD AF 1% CREAM |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
STADOL 2MG/ML VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAGESIC 5MG-500MG CAPSULE |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
STALEVO 100 TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STALEVO 125/200 MG/MG TABLETS |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STALEVO 150 TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STALEVO 200 50-200-200 TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STALEVO 50 TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STARLIX 120MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STARLIX 60MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
STAVZOR 125MG CPDR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
STAVZOR 250MG CPDR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
STAVZOR 500MG CPDR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
STERAPRED 5MG TABLET UNIPAK |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
STERAPRED 5MG TABLET UNIPAK |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
STERAPRED DS 10MG TABLET UNIPAK |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
STERAPRED DS 10MG TABLET UNIPAK |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
STERILE GAUZE PADS 2X 2 |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STIMATE 1.5MG/ML NASAL SPRAY |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
STRATTERA 100MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:1 /1Days |
STRATTERA 10MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:2 /1Days |
STRATTERA 18MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:2 /1Days |
STRATTERA 25MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:2 /1Days |
STRATTERA 40MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:2 /1Days |
STRATTERA 60MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:2 /1Days |
STRATTERA 80MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | S Q:1 /1Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
STRIANT 30MG MUCOADHESIVE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
STROMECTOL 3MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STROMECTOL 6MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SUBOXONE 2MG-0.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SUBOXONE 8MG-2MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SUBUTEX 2MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SUBUTEX 8MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P |
SUCRAID 8500UNITS/ML SOLUTION |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SUCRALFATE 1GM TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULAR 17MG TABLET SR 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
SULAR 25.5MG TABLET SR 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
SULAR 34MG TABLET SR 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SULAR 8.5MG TABLET SR 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULF-10 OPHTHALMIC SOLUTION 10% |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE 10% EYE OINT |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFADIAZINE 500MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE/TMP DS TAB |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMYLON 50G PACKET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SULFASALAZINE 500MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:12 /1Days |
SULFASALAZINE DR 500MG TABLET DELAYED RELEASE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:12 /1Days |
SULFATRIM PEDIATRIC SUSP |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULFAZINE 500MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:12 /1Days |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:12 /1Days |
SULINDAC 150MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SULINDAC 200MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
SUMATRIPTAN |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:5 /30Days |
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:5 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:18 /30Days |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SUPRAX CFIXIME TABLETS USP 400MG 50 TABS BOT |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SURMONTIL 25MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SURMONTIL 50MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SUSTIVA 100MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SUSTIVA 200MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 50MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SUSTIVA 600MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SUTENT 25MG CAPSULE |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SUTENT 50MG CAPSULE |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SYMBYAX 12-25MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
SYMBYAX 12-50MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
SYMBYAX 3MG-25MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
SYMBYAX 6-25MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBYAX 6-50MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
SYMLIN 0.6MG/ML VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
SYNAGIS 100MG/1ML VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
SYNALGOS-DC CAPSULE 356.4MG/30MG |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNERA DIS 70-70MG |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S Q:10 /30Days |
SYNERCID 500MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
SYNTHROID 100MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 112 MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 125MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 137MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 150MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 175MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 200MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 25MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 300MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 50MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 75MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
SYNTHROID 88 MCG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYPRINE 250MG CAPSULE (100 CT) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |