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Blue MedicareRx Premier (PDP) (S5596-003-0)
Tier 1 (1617)
Tier 2 (563)
Tier 3 (1426)
Tier 4 (554)
Tier 5 (339)
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2011 Medicare Part D Plan Formulary Information
Blue MedicareRx Premier (PDP) (S5596-003-0)
Benefit Details           
The Blue MedicareRx Premier (PDP) (S5596-003-0)
Formulary Drugs Starting with the Letter S

in CMS PDP Region 01 which includes: ME NH
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 33%N/AP
SAIZEN 8.8MG CLICK.EASY CARTG   5 Tier 5 33%N/AP
SANCTURA TABLETS   3 Tier 3 $85.00$212.50None
SANCTURA XR 60MG CAPSULE SR 24 HR   3 Tier 3 $85.00$212.50None
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN   5 Tier 5 33%N/AP Q:4
/28Days
SANDIMMUNE 100MG CAPSULE   2 Tier 2 $43.00$107.50P
SANDIMMUNE 100MG/ML TUBEX   2 Tier 2 $43.00$107.50P
SANDIMMUNE 25MG CAPSULE   2 Tier 2 $43.00$107.50P
SANDIMMUNE 50MG/ML AMPUL   4 Tier 4 33%33%P
SANDOSTATIN 0.05MG/ML AMPUL   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SANDOSTATIN 0.1MG/ML AMPUL   5 Tier 5 33%N/ANone
SANDOSTATIN 0.2MG/ML VIAL   5 Tier 5 33%N/ANone
SANDOSTATIN 0.5MG/ML AMPUL   5 Tier 5 33%N/ANone
SANDOSTATIN 1MG/ML VIAL   5 Tier 5 33%N/ANone
SANDOSTATIN LAR 10MG KIT   5 Tier 5 33%N/ANone
SANDOSTATIN LAR 20MG KIT   5 Tier 5 33%N/ANone
SANDOSTATIN LAR 30MG KIT   5 Tier 5 33%N/ANone
SARAFEM TABS   3 Tier 3 $85.00$212.50Q:30
/30Days
SARAFEM TABS   3 Tier 3 $85.00$212.50Q:120
/30Days
SAVELLA TABLETS 100MG 60 COUNT BOT   2 Tier 2 $43.00$107.50Q:60
/30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT   2 Tier 2 $43.00$107.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SAVELLA TABLETS 25MG 60 COUNT BOT   2 Tier 2 $43.00$107.50Q:60
/30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM   2 Tier 2 $43.00$107.50Q:1
/365Days
SAVELLA TALBETS 50MG 60 COUNT BOT   2 Tier 2 $43.00$107.50Q:60
/30Days
SAXAGLIPTIN 2.5 MG ORAL TABLET [ONGLYZA]   2 Tier 2 $43.00$107.50Q:30
/30Days
SAXAGLIPTIN 5 MG ORAL TABLET [ONGLYZA]   2 Tier 2 $43.00$107.50Q:30
/30Days
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS   3 Tier 3 $85.00$212.50Q:91
/91Days
SECTRAL 200MG CAPSULE   3 Tier 3 $85.00$212.50None
SECTRAL 400MG CAPSULE   3 Tier 3 $85.00$212.50None
SELEGILINE HCL 5MG CAPSULE   1 Tier 1 $6.00$9.00None
SELEGILINE HCL 5MG TABLET   1 Tier 1 $6.00$9.00None
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SELFEMRA CAPSULES 10MG 28 CAPSULE BLPK   1 Tier 1 $6.00$9.00Q:30
/30Days
SELFEMRA CAPSULES 20MG 28 CAPSULE 4X7 BLPK   1 Tier 1 $6.00$9.00Q:120
/30Days
SELSUN RX 2.5% SHAMPOO   3 Tier 3 $85.00$212.50None
SELZENTRY 150MG TABLET   5 Tier 5 33%N/ANone
SELZENTRY 300MG TABLET   5 Tier 5 33%N/ANone
SENSIPAR 30MG TABLET   2 Tier 2 $43.00$107.50None
SENSIPAR 60MG TABLET   5 Tier 5 33%N/ANone
SENSIPAR 90MG TABLET   5 Tier 5 33%N/ANone
SEPTRA 80/400 TABLET   3 Tier 3 $85.00$212.50None
SEPTRA DS TABLET 800-160   3 Tier 3 $85.00$212.50None
SEREVENT DIS AER 50MCG   2 Tier 2 $43.00$107.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEROMYCIN CAPSULES 250MG   3 Tier 3 $85.00$212.50None
SEROQUEL 100MG TABLET   2 Tier 2 $43.00$107.50Q:90
/30Days
SEROQUEL 200MG TABLET   2 Tier 2 $43.00$107.50Q:90
/30Days
SEROQUEL 25MG TABLET   2 Tier 2 $43.00$107.50Q:90
/30Days
SEROQUEL 300MG TABLET   2 Tier 2 $43.00$107.50Q:120
/30Days
SEROQUEL 400MG TABLET   2 Tier 2 $43.00$107.50Q:120
/30Days
SEROQUEL 50MG TABLET (100 CT)   2 Tier 2 $43.00$107.50Q:90
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN   2 Tier 2 $43.00$107.50Q:30
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN   2 Tier 2 $43.00$107.50Q:30
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN   2 Tier 2 $43.00$107.50Q:120
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN   2 Tier 2 $43.00$107.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEROQUEL XR 300MG TABLET 60X300MG BOT   2 Tier 2 $43.00$107.50Q:90
/30Days
SEROSTIM 4MG VIAL   5 Tier 5 33%N/AP
SEROSTIM 5MG VIAL   5 Tier 5 33%N/AP
SEROSTIM 6MG VIAL   5 Tier 5 33%N/AP
SERTRALINE HCL 100MG TABLET (30 CT)   1 Tier 1 $6.00$9.00Q:90
/30Days
SERTRALINE HCL 25 MG TABLET   1 Tier 1 $6.00$9.00Q:60
/30Days
SERTRALINE HCL 50MG TABLET (30 CT)   1 Tier 1 $6.00$9.00Q:60
/30Days
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE   1 Tier 1 $6.00$9.00Q:300
/30Days
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]   2 Tier 2 $43.00$107.50None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]   2 Tier 2 $43.00$107.50None
SILVADENE 1% CREAM   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SILVER SULFADIAZINE 1% CRM   1 Tier 1 $6.00$9.00None
SIMCOR 1000-20MG TABLET MULTIPHASIC RELEASE 24HR   2 Tier 2 $43.00$107.50Q:60
/30Days
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR   2 Tier 2 $43.00$107.50Q:60
/30Days
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR   2 Tier 2 $43.00$107.50Q:60
/30Days
SIMCOR TABLETS EXTENDED RELEASE   2 Tier 2 $43.00$107.50Q:30
/30Days
SIMCOR TABLETS EXTENDED RELEASE   2 Tier 2 $43.00$107.50Q:30
/30Days
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR   5 Tier 5 33%N/AP Q:1
/28Days
SIMULECT 20MG VIAL   5 Tier 5 33%N/AP
SIMVASTATIN 10MG TABLET (30 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
SIMVASTATIN 20MG TABLET 10000 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
SIMVASTATIN 40MG TABLET (500 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SIMVASTATIN 5MG TABLET (90 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
SIMVASTATIN 80MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
SINEMET CR 25/100 TABLET SA   3 Tier 3 $85.00$212.50None
SINEMET CR 50/200 TABLET SA   3 Tier 3 $85.00$212.50None
SINEMET-10/100 TABLET   3 Tier 3 $85.00$212.50None
SINEMET-25/100 TABLET   3 Tier 3 $85.00$212.50None
SINEMET-25/250 TABLET   3 Tier 3 $85.00$212.50None
SINGULAIR 10MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
SINGULAIR 4MG GRANULES   2 Tier 2 $43.00$107.50Q:30
/30Days
SINGULAIR 4MG TABLET CHEW   2 Tier 2 $43.00$107.50Q:30
/30Days
SINGULAIR 5MG TABLET CHEW   2 Tier 2 $43.00$107.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SKELAXIN 800MG TABLET   3 Tier 3 $85.00$212.50None
SKELID 200MG TABLET   3 Tier 3 $85.00$212.50None
SODIUM BICARB INJ 7.5%   4 Tier 4 33%33%None
SODIUM BICARB INJ 8.4%   4 Tier 4 33%33%None
SODIUM CHLORIDE 0.45% TUBEX   4 Tier 4 33%33%None
SODIUM CHLORIDE INJECTION 3% 24X500ML BAG   4 Tier 4 33%33%None
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR   4 Tier 4 33%33%None
SODIUM CHLORIDE INJECTION USP 5%   4 Tier 4 33%33%None
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE   4 Tier 4 33%33%None
SODIUM CL 2.5 MEQ/ML VIAL   4 Tier 4 33%33%None
SODIUM EDECRIN FOR INJECTION 50MG 1 X 50 MG VIAL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SODIUM FLUORIDE 1MG TABLET   1 Tier 1 $6.00$9.00None
SODIUM LACTATE 1/6MOLAR INJ   4 Tier 4 33%33%None
SODIUM LACTATE 5 MEQ/ML VIAL   4 Tier 4 33%33%None
SODIUM POLYSTYRENE SULFONATE POWDER   1 Tier 1 $6.00$9.00None
SOLARAZE 3% GEL   2 Tier 2 $43.00$107.50None
SOLIA 0.15-0.03 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
SOLODYN 135MG TABLET   3 Tier 3 $85.00$212.50None
SOLODYN 45MG TABLET SR 24HR (100 CT)   3 Tier 3 $85.00$212.50None
SOLODYN 90MG TABLET   3 Tier 3 $85.00$212.50None
SOLODYN ER 115 MG TABLET   3 Tier 3 $85.00$212.50None
SOLODYN ER 65 MG TABLET   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOLU CORTEF INJECTION   4 Tier 4 33%33%None
SOLU CORTEF INJECTION 100 MG/VIAL   4 Tier 4 33%33%None
SOLU MEDROL 125 MG AOV 25, 125MG/2ML   4 Tier 4 33%33%None
SOLU MEDROL FOR INJECTION 40 MG/ML   4 Tier 4 33%33%None
SOLU MEDROL FOR INJECTION 500 MG/ML   4 Tier 4 33%33%None
SOLU-MEDROL 2000MG VIAL   4 Tier 4 33%33%None
SOMA 250MG TABLET   3 Tier 3 $85.00$212.50None
SOMA TABLETS   3 Tier 3 $85.00$212.50None
SOMATROPIN INJECTION KIT 5.8MG/1.14ML 1 PKGCOM   5 Tier 5 33%N/AP
SOMAVERT 10MG VIAL   5 Tier 5 33%N/ANone
SOMAVERT 15MG VIAL   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOMAVERT 20MG VIAL   5 Tier 5 33%N/ANone
SONATA 10MG CAPSULE   3 Tier 3 $85.00$212.50P Q:60
/30Days
SONATA 5MG CAPSULE   3 Tier 3 $85.00$212.50P Q:30
/30Days
SORIATANE 17.5 MG CAPSULE   5 Tier 5 33%N/ANone
SORIATANE 22.5 MG CAPSULE   5 Tier 5 33%N/ANone
SORIATANE CAPSULES   3 Tier 3 $85.00$212.50None
SORIATANE CAPSULES   5 Tier 5 33%N/ANone
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   1 Tier 1 $6.00$9.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   1 Tier 1 $6.00$9.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   1 Tier 1 $6.00$9.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOTALOL HCL 120MG TABLET 100 BOT   1 Tier 1 $6.00$9.00None
SOTALOL HCL 160MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
SOTALOL HCL 80MG TABLET   1 Tier 1 $6.00$9.00None
SOTALOL HCL TABLET 240MG   1 Tier 1 $6.00$9.00None
SOTALOL HYDROCHLORIDE INJECTION 15MG/ML   4 Tier 4 33%33%None
SOTRET 10MG CAPSULE   1 Tier 1 $6.00$9.00None
SOTRET 20MG CAPSULE   1 Tier 1 $6.00$9.00None
SOTRET 30MG CAPSULE   1 Tier 1 $6.00$9.00None
SOTRET 40MG CAPSULE   1 Tier 1 $6.00$9.00None
SPECTRACEF 400 MG DOSE PACK TB   3 Tier 3 $85.00$212.50None
SPECTRACEF TABLETS 200 MG   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK   2 Tier 2 $43.00$107.50Q:30
/30Days
SPIRONOLACTONE 100MG TABLET   1 Tier 1 $6.00$9.00None
SPIRONOLACTONE 25MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
SPIRONOLACTONE 50MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)   1 Tier 1 $6.00$9.00None
SPORANOX 100MG CAPSULE   3 Tier 3 $85.00$212.50P
SPORANOX 100MG CAPSULE   3 Tier 3 $85.00$212.50P
SPORANOX 10MG/ML SOLUTION   3 Tier 3 $85.00$212.50None
SPRINTEC 0.25-0.035 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
SPRYCEL 20MG TABLET   5 Tier 5 33%N/AP
SPRYCEL 50MG TABLET   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPRYCEL 70MG TABLET   5 Tier 5 33%N/AP
SPRYCEL TABLETS   5 Tier 5 33%N/AP
SRONYX 0.1-0.02 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
SSD 1% CREAM   1 Tier 1 $6.00$9.00None
STADOL 2MG/ML VIAL   4 Tier 4 33%33%None
STAGESIC 5MG-500MG CAPSULE   1 Tier 1 $6.00$9.00Q:240
/30Days
STALEVO 100 TABLET   2 Tier 2 $43.00$107.50None
STALEVO 125/200 MG/MG TABLETS   2 Tier 2 $43.00$107.50None
STALEVO 150 TABLET   2 Tier 2 $43.00$107.50None
STALEVO 18.75/75 MG/MG TABLETS   2 Tier 2 $43.00$107.50None
STALEVO 200 50-200-200 TABLET   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STALEVO 50 TABLET   2 Tier 2 $43.00$107.50None
STARLIX 120MG TABLET   3 Tier 3 $85.00$212.50None
STARLIX 60MG TABLET   3 Tier 3 $85.00$212.50None
STAVUDINE CAPSULES 15MG 60 BOT   1 Tier 1 $6.00$9.00None
STAVUDINE CAPSULES 20MG 60 BOT   1 Tier 1 $6.00$9.00None
STAVUDINE CAPSULES 30MG 60 BOT   1 Tier 1 $6.00$9.00None
STAVUDINE CAPSULES 40MG 60 BOT   1 Tier 1 $6.00$9.00None
STAVUDINE FOR ORAL SOLUTION 1MG/ML 200 ML BOT   1 Tier 1 $6.00$9.00None
STAVZOR 125MG CPDR   3 Tier 3 $85.00$212.50Q:60
/30Days
STAVZOR 250MG CPDR   3 Tier 3 $85.00$212.50Q:60
/30Days
STAVZOR 500MG CPDR   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STELARA 45 MG/0.5 ML SYRINGE   5 Tier 5 33%N/AP Q:1
/28Days
STELARA 45 MG/0.5 ML VIAL   5 Tier 5 33%N/AP Q:1
/28Days
STELARA 90 MG/ML SYRINGE   5 Tier 5 33%N/AP Q:1
/28Days
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL   4 Tier 4 33%33%P
STERILE VANCOMYCIN HYDROCHLORIDE INJECTION   4 Tier 4 33%33%P
STERILE WATER FOR IRRIGATION 100 24 X 500ML BAG   4 Tier 4 33%33%P
STIMATE 1.5MG/ML NASAL SPRAY   3 Tier 3 $85.00$212.50None
STREPTOMYCIN FOR INJECTION 1GM/VIL   4 Tier 4 33%33%None
STROMECTOL 3MG TABLET   2 Tier 2 $43.00$107.50None
SUBOXONE 2MG-0.5MG TABLET   2 Tier 2 $43.00$107.50P
SUBOXONE 8MG-2MG TABLET   2 Tier 2 $43.00$107.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUBUTEX 2MG TABLET   3 Tier 3 $85.00$212.50P Q:240
/30Days
SUBUTEX 8MG TABLET   3 Tier 3 $85.00$212.50P Q:60
/30Days
SUCRALFATE 1GM TABLET   1 Tier 1 $6.00$9.00None
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL   1 Tier 1 $6.00$9.00None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   1 Tier 1 $6.00$9.00None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS   1 Tier 1 $6.00$9.00None
SULFADIAZINE 500MG TABLET   1 Tier 1 $6.00$9.00None
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL   4 Tier 4 33%33%None
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT   1 Tier 1 $6.00$9.00None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SULFAMYLON 50G PACKET   3 Tier 3 $85.00$212.50None
SULFAMYLON CREAM 85GM 4 OZ TUBE   3 Tier 3 $85.00$212.50None
SULFASALAZINE 500MG TABLET   1 Tier 1 $6.00$9.00None
SULFATRIM PEDIATRIC SUSP   1 Tier 1 $6.00$9.00None
SULFAZINE EC 500MG TABLET DELAYED RELEASE   1 Tier 1 $6.00$9.00None
SULINDAC 150MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
SULINDAC 200MG TABLET   1 Tier 1 $6.00$9.00None
SUMATRIPTAN   4 Tier 4 33%33%Q:4
/30Days
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD   4 Tier 4 33%33%Q:4
/30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD   1 Tier 1 $6.00$9.00Q:9
/30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX   1 Tier 1 $6.00$9.00Q:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX   1 Tier 1 $6.00$9.00Q:9
/30Days
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT   3 Tier 3 $85.00$212.50None
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Tier 3 $85.00$212.50None
SUPRAX CFIXIME TABLETS USP 400MG 50 TABS BOT   3 Tier 3 $85.00$212.50Q:14
/30Days
SURMONTIL 100MG CAPSULE   3 Tier 3 $85.00$212.50None
SURMONTIL 25MG CAPSULE   3 Tier 3 $85.00$212.50None
SURMONTIL 50MG CAPSULE   3 Tier 3 $85.00$212.50None
SUSTIVA 200MG CAPSULE   2 Tier 2 $43.00$107.50None
SUSTIVA 50MG CAPSULE   2 Tier 2 $43.00$107.50None
SUSTIVA 600MG TABLET   2 Tier 2 $43.00$107.50None
SUTENT 12.5MG CAPSULE   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUTENT 25MG CAPSULE   5 Tier 5 33%N/AP
SUTENT 50MG CAPSULE   5 Tier 5 33%N/AP
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   2 Tier 2 $43.00$107.50Q:11
/30Days
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL   2 Tier 2 $43.00$107.50Q:11
/30Days
SYMBYAX 12-25MG CAPSULE   3 Tier 3 $85.00$212.50Q:30
/30Days
SYMBYAX 12-50MG CAPSULE   3 Tier 3 $85.00$212.50Q:30
/30Days
SYMBYAX 3MG-25MG CAPSULE   3 Tier 3 $85.00$212.50Q:30
/30Days
SYMBYAX 6-25MG CAPSULE   3 Tier 3 $85.00$212.50Q:30
/30Days
SYMBYAX 6-50MG CAPSULE   3 Tier 3 $85.00$212.50Q:30
/30Days
SYMLIN 0.6MG/ML VIAL   2 Tier 2 $43.00$107.50None
SYMLINPEN 120 1000MCG/ML PEN INJECTOR   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMLINPEN 60 1000MCG/ML PEN INJECTOR   2 Tier 2 $43.00$107.50None
SYNALGOS DC CAPSULES 16;356.4;MG;MG;MG;   3 Tier 3 $85.00$212.50None
SYNAREL 2MG/ML NASAL SPRAY   5 Tier 5 33%N/AP
SYNTHROID 100MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 112 MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 125MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 137MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 150MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 175MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 200MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 25MCG TABLET   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 300MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 50MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 75MCG TABLET   2 Tier 2 $43.00$107.50None
SYNTHROID 88 MCG TABLET   2 Tier 2 $43.00$107.50None
SYPRINE 250MG CAPSULE (100 CT)   2 Tier 2 $43.00$107.50None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Blue MedicareRx Premier (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2011 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.





 
 

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.