2011 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Premier (PDP) (S5810-193-0)
Sanctioned Plan
|
The Aetna Medicare Rx Premier (PDP) (S5810-193-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 23 which includes: OK
|
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 |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Tier 5 |
25% | 25% | P S Q:4 /30Days |
SANDOSTATIN LAR 10MG KIT |
5 |
Tier 5 |
25% | 25% | P S |
SANDOSTATIN LAR 20MG KIT |
5 |
Tier 5 |
25% | 25% | P S |
SANDOSTATIN LAR 30MG KIT |
5 |
Tier 5 |
25% | 25% | P S |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3 |
Tier 3 |
$25.00 | $60.00 | Q:55 /365Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SELEGILINE HCL 5MG CAPSULE |
1 |
Tier 1 |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELEGILINE HCL 5MG TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SELFEMRA CAPSULES 10MG 28 CAPSULE BLPK |
2 |
Tier 2 |
$20.00 | $45.00 | Q:1 /1Days |
SELFEMRA CAPSULES 20MG 28 CAPSULE 4X7 BLPK |
2 |
Tier 2 |
$20.00 | $45.00 | Q:4 /1Days |
SELZENTRY 150MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
SELZENTRY 300MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
SEMPREX-D 60/8 CAPSULE |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SENSIPAR 30MG TABLET |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SENSIPAR 60MG TABLET |
5 |
Tier 5 |
25% | 25% | Q:2 /1Days |
SENSIPAR 90MG TABLET |
5 |
Tier 5 |
25% | 25% | Q:4 /1Days |
SEROMYCIN CAPSULES 250MG |
2 |
Tier 2 |
$20.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 100MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | Q:3 /1Days |
SEROQUEL 200MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | Q:4 /1Days |
SEROQUEL 25MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | Q:6 /1Days |
SEROQUEL 300MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | Q:2 /1Days |
SEROQUEL 400MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | Q:2 /1Days |
SEROQUEL 50MG TABLET (100 CT) |
4 |
Tier 4 |
$60.00 | $165.00 | Q:3 /1Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Tier 3 |
$25.00 | $60.00 | Q:6 /1Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | Q:2 /1Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | Q:1 /1Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | Q:2 /1Days |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE |
2 |
Tier 2 |
$20.00 | $45.00 | Q:10 /1Days |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Tier 3 |
$25.00 | $60.00 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Tier 3 |
$25.00 | $60.00 | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SIMCOR 1000-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SIMCOR TABLETS EXTENDED RELEASE |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMCOR TABLETS EXTENDED RELEASE |
3 |
Tier 3 |
$25.00 | $60.00 | Q:2 /1Days |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Tier 5 |
25% | 25% | P Q:50 /28Days |
SIMULECT 20MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SIMVASTATIN 10MG TABLET (30 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | Q:1 /1Days |
SIMVASTATIN 20MG TABLET 10000 BOT |
1 |
Tier 1 |
$2.00 | $6.00 | Q:1 /1Days |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | Q:1 /1Days |
SIMVASTATIN 5MG TABLET (90 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | Q:1 /1Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | Q:1 /1Days |
SINGULAIR 10MG TABLET |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
SINGULAIR 4MG GRANULES |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
SINGULAIR 4MG TABLET CHEW |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SINGULAIR 5MG TABLET CHEW |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
SODIUM BICARB INJ 7.5% |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM BICARB INJ 8.4% |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM CHLORIDE INJECTION 3% 24X500ML BAG |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM FLUORIDE 1MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SODIUM LACTATE 1/6MOLAR INJ |
1 |
Tier 1 |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SODIUM POLYSTYRENE SULFONATE POWDER |
2 |
Tier 2 |
$20.00 | $45.00 | None |
SOLARAZE 3% GEL |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SOLIA 0.15-0.03 TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Tier 5 |
25% | 25% | P |
SOMAVERT 10MG VIAL |
5 |
Tier 5 |
25% | 25% | P S |
SOMAVERT 15MG VIAL |
5 |
Tier 5 |
25% | 25% | P S |
SOMAVERT 20MG VIAL |
5 |
Tier 5 |
25% | 25% | P S |
SORIATANE 17.5 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | None |
SORIATANE 22.5 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | None |
SORIATANE CAPSULES |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORIATANE CAPSULES |
5 |
Tier 5 |
25% | 25% | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SOTALOL HCL 80MG TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SOTALOL HYDROCHLORIDE INJECTION 15MG/ML |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SOTRET 10MG CAPSULE |
2 |
Tier 2 |
$20.00 | $45.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTRET 20MG CAPSULE |
2 |
Tier 2 |
$20.00 | $45.00 | P |
SOTRET 30MG CAPSULE |
2 |
Tier 2 |
$20.00 | $45.00 | P |
SOTRET 40MG CAPSULE |
2 |
Tier 2 |
$20.00 | $45.00 | P |
SPECTRACEF 400 MG DOSE PACK TB |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SPECTRACEF TABLETS 200 MG |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Tier 3 |
$25.00 | $60.00 | Q:1 /1Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SPORANOX 10MG/ML SOLUTION |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRINTEC 0.25-0.035 TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:2 /1Days |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:2 /1Days |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:2 /1Days |
SPRYCEL TABLETS |
5 |
Tier 5 |
25% | 25% | P Q:1 /1Days |
SRONYX 0.1-0.02 TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SSD 1% CREAM |
1 |
Tier 1 |
$2.00 | $6.00 | None |
STAGESIC 5MG-500MG CAPSULE |
1 |
Tier 1 |
$2.00 | $6.00 | Q:8 /1Days |
STALEVO 100 TABLET |
3 |
Tier 3 |
$25.00 | $60.00 | None |
STALEVO 125/200 MG/MG TABLETS |
3 |
Tier 3 |
$25.00 | $60.00 | None |
STALEVO 150 TABLET |
3 |
Tier 3 |
$25.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STALEVO 18.75/75 MG/MG TABLETS |
3 |
Tier 3 |
$25.00 | $60.00 | None |
STALEVO 200 50-200-200 TABLET |
3 |
Tier 3 |
$25.00 | $60.00 | None |
STALEVO 50 TABLET |
3 |
Tier 3 |
$25.00 | $60.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
STAVUDINE FOR ORAL SOLUTION 1MG/ML 200 ML BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
25% | 25% | P Q:1 /1Days |
STELARA 45 MG/0.5 ML VIAL |
5 |
Tier 5 |
25% | 25% | P Q:1 /1Days |
STELARA 90 MG/ML SYRINGE |
5 |
Tier 5 |
25% | 25% | P Q:1 /1Days |
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 |
2 |
Tier 2 |
$20.00 | $45.00 | P |
STERILE VANCOMYCIN HYDROCHLORIDE INJECTION |
4 |
Tier 4 |
$60.00 | $165.00 | P |
STERILE WATER FOR IRRIGATION 100 24 X 500ML BAG |
1 |
Tier 1 |
$2.00 | $6.00 | None |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Tier 1 |
$2.00 | $6.00 | None |
STROMECTOL 3MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SUBOXONE 2MG-0.5MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | P Q:3 /1Days |
SUBOXONE 8MG-2MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | P Q:3 /1Days |
SUCRALFATE 1GM TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Tier 1 |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFADIAZINE 500MG TABLET |
2 |
Tier 2 |
$20.00 | $45.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
2 |
Tier 2 |
$20.00 | $45.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFATRIM PEDIATRIC SUSP |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SULINDAC 200MG TABLET |
1 |
Tier 1 |
$2.00 | $6.00 | None |
SUMATRIPTAN |
2 |
Tier 2 |
$20.00 | $45.00 | Q:5 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD |
2 |
Tier 2 |
$20.00 | $45.00 | Q:5 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Tier 2 |
$20.00 | $45.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
2 |
Tier 2 |
$20.00 | $45.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
2 |
Tier 2 |
$20.00 | $45.00 | Q:18 /30Days |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$20.00 | $45.00 | None |
SUPRAX CFIXIME TABLETS USP 400MG 50 TABS BOT |
2 |
Tier 2 |
$20.00 | $45.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SURMONTIL 25MG CAPSULE |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SURMONTIL 50MG CAPSULE |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SUSTIVA 200MG CAPSULE |
4 |
Tier 4 |
$60.00 | $165.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 50MG CAPSULE |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SUSTIVA 600MG TABLET |
4 |
Tier 4 |
$60.00 | $165.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P Q:3 /1Days |
SUTENT 25MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P Q:3 /1Days |
SUTENT 50MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P Q:1 /1Days |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Tier 3 |
$25.00 | $60.00 | Q:11 /25Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
3 |
Tier 3 |
$25.00 | $60.00 | Q:11 /25Days |
SYMLIN 0.6MG/ML VIAL |
4 |
Tier 4 |
$60.00 | $165.00 | Q:20 /30Days |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Tier 5 |
25% | 25% | None |
SYNERCID 500MG VIAL |
5 |
Tier 5 |
25% | 25% | 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 |
$60.00 | $165.00 | None |