2011 Medicare Part D Plan Formulary Information |
Triple-S Medicare Optimo Premier (HMO) (H5732-001-0)
Benefit Details
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The Triple-S Medicare Optimo Premier (HMO) (H5732-001-0) Formulary Drugs Starting with the Letter S in Jayuya County, PR: CMS MA Region 0 which includes: PR
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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 |
SAIZEN 5MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SAIZEN 8.8MG CLICK.EASY CARTG |
5 |
Tier 5 |
25% | 25% | P |
SANDIMMUNE 100MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SANDIMMUNE 25MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SANDOSTATIN 0.05MG/ML AMPUL |
5 |
Tier 5 |
25% | 25% | P |
SANDOSTATIN 0.1MG/ML AMPUL |
5 |
Tier 5 |
25% | 25% | P |
SANDOSTATIN 0.2MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
SANDOSTATIN 0.5MG/ML AMPUL |
5 |
Tier 5 |
25% | 25% | P |
SANDOSTATIN 1MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDOSTATIN LAR 10MG KIT |
5 |
Tier 5 |
25% | 25% | P |
SANDOSTATIN LAR 20MG KIT |
5 |
Tier 5 |
25% | 25% | P |
SANDOSTATIN LAR 30MG KIT |
5 |
Tier 5 |
25% | 25% | P |
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SECTRAL 200MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SECTRAL 400MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SELSUN RX 2.5% SHAMPOO |
4 |
Tier 4 |
$50.00 | $100.00 | Q:120 /15Days |
SELZENTRY 150MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
SELZENTRY 300MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SENSIPAR 30MG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | P |
SENSIPAR 60MG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | P |
SENSIPAR 90MG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | P |
SEPTRA 80/400 TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SEPTRA DS TABLET 800-160 |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SEROMYCIN CAPSULES 250MG |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SEROQUEL 100MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL 200MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL 25MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL 300MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL 400MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 50MG TABLET (100 CT) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROSTIM 4MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SEROSTIM 5MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SEROSTIM 6MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
2 |
Tier 2 |
$30.00 | $60.00 | P |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
2 |
Tier 2 |
$30.00 | $60.00 | P |
SILVADENE 1% CREAM |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILVER SULFADIAZINE 1% CRM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SIMVASTATIN 10MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SIMVASTATIN 20MG TABLET 10000 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SIMVASTATIN 5MG TABLET (90 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SINEMET CR 25/100 TABLET SA |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SINEMET CR 50/200 TABLET SA |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SINEMET-10/100 TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SINEMET-25/100 TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SINEMET-25/250 TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SINGULAIR 10MG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | S |
SINGULAIR 4MG GRANULES |
2 |
Tier 2 |
$30.00 | $60.00 | S |
SINGULAIR 4MG TABLET CHEW |
2 |
Tier 2 |
$30.00 | $60.00 | S |
SINGULAIR 5MG TABLET CHEW |
2 |
Tier 2 |
$30.00 | $60.00 | S |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Tier 1 |
$5.00 | $10.00 | P |
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR |
1 |
Tier 1 |
$5.00 | $10.00 | P |
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | P |
SODIUM FLUORIDE 1MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SODIUM POLYSTYRENE SULFONATE POWDER |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SOLARAZE 3% GEL |
4 |
Tier 4 |
$50.00 | $100.00 | Q:100 /15Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLU CORTEF INJECTION |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SOLU CORTEF INJECTION 100 MG/VIAL |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SOLU MEDROL 125 MG AOV 25, 125MG/2ML |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SOLU MEDROL FOR INJECTION 40 MG/ML |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SOMATROPIN INJECTION KIT 5.8MG/1.14ML 1 PKGCOM |
5 |
Tier 5 |
25% | 25% | P |
SOMAVERT 10MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SOMAVERT 15MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SOMAVERT 20MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
SONATA 10MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | S |
SONATA 5MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | S |
SORIATANE 17.5 MG CAPSULE |
3 |
Tier 3 |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORIATANE 22.5 MG CAPSULE |
3 |
Tier 3 |
$45.00 | $90.00 | None |
SORIATANE CAPSULES |
3 |
Tier 3 |
$45.00 | $90.00 | None |
SORIATANE CAPSULES |
3 |
Tier 3 |
$45.00 | $90.00 | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SOTALOL HCL 80MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SOTRET 30MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SPIRONOLACTONE 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SPORANOX 100MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SPORANOX 100MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
SPRYCEL TABLETS |
5 |
Tier 5 |
25% | 25% | P |
STALEVO 100 TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
STALEVO 125/200 MG/MG TABLETS |
2 |
Tier 2 |
$30.00 | $60.00 | None |
STALEVO 150 TABLET |
2 |
Tier 2 |
$30.00 | $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 |
2 |
Tier 2 |
$30.00 | $60.00 | None |
STALEVO 200 50-200-200 TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
STALEVO 50 TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
STARLIX 120MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | S |
STARLIX 60MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | S |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
STAVUDINE FOR ORAL SOLUTION 1MG/ML 200 ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STIMATE 1.5MG/ML NASAL SPRAY |
5 |
Tier 5 |
25% | 25% | None |
STRATTERA 100MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STRATTERA 10MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STRATTERA 18MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STRATTERA 25MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STRATTERA 40MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STRATTERA 60MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STRATTERA 80MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STROMECTOL 3MG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SUBOXONE 2MG-0.5MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SUBOXONE 8MG-2MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBUTEX 2MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SUBUTEX 8MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SUCRALFATE 1GM TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULFADIAZINE 500MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
3 |
Tier 3 |
$45.00 | $90.00 | P |
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SULINDAC 200MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
SUMATRIPTAN |
4 |
Tier 4 |
$50.00 | $100.00 | Q:5 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Tier 1 |
$5.00 | $10.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
1 |
Tier 1 |
$5.00 | $10.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
1 |
Tier 1 |
$5.00 | $10.00 | Q:18 /30Days |
SUPRAX CFIXIME TABLETS USP 400MG 50 TABS BOT |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SURMONTIL 25MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SURMONTIL 50MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 200MG CAPSULE |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SUSTIVA 50MG CAPSULE |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SUSTIVA 600MG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
SUTENT 25MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
SUTENT 50MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
2 |
Tier 2 |
$30.00 | $60.00 | Q:10 /30Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
2 |
Tier 2 |
$30.00 | $60.00 | Q:10 /30Days |
SYMBYAX 12-25MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SYMBYAX 12-50MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SYMBYAX 3MG-25MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBYAX 6-25MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SYMBYAX 6-50MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SYMLIN 0.6MG/ML VIAL |
4 |
Tier 4 |
$50.00 | $100.00 | P Q:25 /30Days |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
4 |
Tier 4 |
$50.00 | $100.00 | P Q:14 /30Days |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Tier 5 |
25% | 25% | None |
SYNTHROID 100MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 112 MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 125MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 137MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 150MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 175MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 200MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 25MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 300MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 50MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 75MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |
SYNTHROID 88 MCG TABLET |
2 |
Tier 2 |
$30.00 | $60.00 | None |