2012 Medicare Part D Plan Formulary Information |
IU Health Plans Medicare Select Plus (HMO) (H7220-003-0)
Benefit Details
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The IU Health Plans Medicare Select Plus (HMO) (H7220-003-0) Formulary Drugs Starting with the Letter S in Henry County, IN: CMS MA Region 13 which includes: IN
|
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 |
SANDIMMUNE 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SANDIMMUNE 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SANDIMMUNE 100MG/ML TUBEX ![Compare how all Medicare Part D PDP plans in IN cover SANDIMMUNE 100MG/ML TUBEX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SANDIMMUNE 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SANDIMMUNE 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SANDIMMUNE 50MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in IN cover SANDIMMUNE 50MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SANDOSTATIN 0.05MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in IN cover SANDOSTATIN 0.05MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SANDOSTATIN 0.2MG/ML VIAL ![Compare how all Medicare Part D PDP plans in IN cover SANDOSTATIN 0.2MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE ![Compare how all Medicare Part D PDP plans in IN cover Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SANDOSTATIN 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in IN cover SANDOSTATIN 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE ![Compare how all Medicare Part D PDP plans in IN cover Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SANDOSTATIN LAR 10MG KIT ![Compare how all Medicare Part D PDP plans in IN cover SANDOSTATIN LAR 10MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDOSTATIN LAR 20MG KIT ![Compare how all Medicare Part D PDP plans in IN cover SANDOSTATIN LAR 20MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SANDOSTATIN LAR 30MG KIT ![Compare how all Medicare Part D PDP plans in IN cover SANDOSTATIN LAR 30MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK ![Compare how all Medicare Part D PDP plans in IN cover SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK ![Compare how all Medicare Part D PDP plans in IN cover SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SAVELLA TABLETS 100MG 60 COUNT BOT ![Compare how all Medicare Part D PDP plans in IN cover SAVELLA TABLETS 100MG 60 COUNT BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SAVELLA TABLETS 12.5MG 60 COUNT BOT ![Compare how all Medicare Part D PDP plans in IN cover SAVELLA TABLETS 12.5MG 60 COUNT BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SAVELLA TABLETS 25MG 60 COUNT BOT ![Compare how all Medicare Part D PDP plans in IN cover SAVELLA TABLETS 25MG 60 COUNT BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM ![Compare how all Medicare Part D PDP plans in IN cover SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SAVELLA TALBETS 50MG 60 COUNT BOT ![Compare how all Medicare Part D PDP plans in IN cover SAVELLA TALBETS 50MG 60 COUNT BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS ![Compare how all Medicare Part D PDP plans in IN cover SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SECTRAL 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SECTRAL 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SECTRAL 400MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SECTRAL 400MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SELEGILINE HCL 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SELEGILINE HCL 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Selegiline Hydrochloride 5mg/1 60 TABLET in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in IN cover Selegiline Hydrochloride 5mg/1 60 TABLET in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | None |
SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | None |
SENSIPAR 30MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SENSIPAR 30MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SENSIPAR 60MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SENSIPAR 60MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SENSIPAR 90MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SENSIPAR 90MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
SEPTRA 80/400 TABLET ![Compare how all Medicare Part D PDP plans in IN cover SEPTRA 80/400 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SEPTRA DS TABLET 800-160 ![Compare how all Medicare Part D PDP plans in IN cover SEPTRA DS TABLET 800-160.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEREVENT DIS AER 50MCG ![Compare how all Medicare Part D PDP plans in IN cover SEREVENT DIS AER 50MCG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL 100MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL 200MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL 25MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL 300MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL 400MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL 400MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SEROQUEL XR 300MG TABLET 60X300MG BOT ![Compare how all Medicare Part D PDP plans in IN cover SEROQUEL XR 300MG TABLET 60X300MG BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON ![Compare how all Medicare Part D PDP plans in IN cover Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON ![Compare how all Medicare Part D PDP plans in IN cover Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SERTRALINE HCL 100MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in IN cover SERTRALINE HCL 100MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SERTRALINE HCL 25 MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SERTRALINE HCL 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SERTRALINE HCL 50MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in IN cover SERTRALINE HCL 50MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE ![Compare how all Medicare Part D PDP plans in IN cover SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] ![Compare how all Medicare Part D PDP plans in IN cover SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] ![Compare how all Medicare Part D PDP plans in IN cover SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
sF Rowasa 4g/60mL ![Compare how all Medicare Part D PDP plans in IN cover sF Rowasa 4g/60mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILVADENE 1% CREAM ![Compare how all Medicare Part D PDP plans in IN cover SILVADENE 1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SILVER SULFADIAZINE 1% CRM ![Compare how all Medicare Part D PDP plans in IN cover SILVER SULFADIAZINE 1% CRM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR ![Compare how all Medicare Part D PDP plans in IN cover SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR ![Compare how all Medicare Part D PDP plans in IN cover SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SIMCOR TABLETS EXTENDED RELEASE ![Compare how all Medicare Part D PDP plans in IN cover SIMCOR TABLETS EXTENDED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SIMCOR TABLETS EXTENDED RELEASE ![Compare how all Medicare Part D PDP plans in IN cover SIMCOR TABLETS EXTENDED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR ![Compare how all Medicare Part D PDP plans in IN cover SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SIMULECT 20MG VIAL ![Compare how all Medicare Part D PDP plans in IN cover SIMULECT 20MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SIMVASTATIN 20MG TABLET 10000 BOT ![Compare how all Medicare Part D PDP plans in IN cover SIMVASTATIN 20MG TABLET 10000 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SIMVASTATIN 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in IN cover SIMVASTATIN 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Simvastatin 5mg/1 ![Compare how all Medicare Part D PDP plans in IN cover Simvastatin 5mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SIMVASTATIN 80MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in IN cover SIMVASTATIN 80MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SINEMET 10; 100mg/1; mg/1 100 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SINEMET 10; 100mg/1; mg/1 100 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SINGULAIR 10MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SINGULAIR 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SINGULAIR 4MG GRANULES ![Compare how all Medicare Part D PDP plans in IN cover SINGULAIR 4MG GRANULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SINGULAIR 4MG TABLET CHEW ![Compare how all Medicare Part D PDP plans in IN cover SINGULAIR 4MG TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SINGULAIR 5MG TABLET CHEW ![Compare how all Medicare Part D PDP plans in IN cover SINGULAIR 5MG TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SOD POLY SUL SUS 15GM/60 ![Compare how all Medicare Part D PDP plans in IN cover SOD POLY SUL SUS 15GM/60.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SODIUM BICARB INJ 7.5% ![Compare how all Medicare Part D PDP plans in IN cover SODIUM BICARB INJ 7.5%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM BICARB INJ 8.4% ![Compare how all Medicare Part D PDP plans in IN cover SODIUM BICARB INJ 8.4%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | P |
Sodium Chloride 3g/100mL ![Compare how all Medicare Part D PDP plans in IN cover Sodium Chloride 3g/100mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in IN cover Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG ![Compare how all Medicare Part D PDP plans in IN cover Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SODIUM CL 2.5 MEQ/ML VIAL ![Compare how all Medicare Part D PDP plans in IN cover SODIUM CL 2.5 MEQ/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | P |
SOLARAZE 3% GEL ![Compare how all Medicare Part D PDP plans in IN cover SOLARAZE 3% GEL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SOLIA 0.15-0.03 TABLET ![Compare how all Medicare Part D PDP plans in IN cover SOLIA 0.15-0.03 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOMATULINE 60 MG/0.2 ML SYRING ![Compare how all Medicare Part D PDP plans in IN cover SOMATULINE 60 MG/0.2 ML SYRING.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE ![Compare how all Medicare Part D PDP plans in IN cover Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SOMAVERT 10MG VIAL ![Compare how all Medicare Part D PDP plans in IN cover SOMAVERT 10MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SOMAVERT 15MG VIAL ![Compare how all Medicare Part D PDP plans in IN cover SOMAVERT 15MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 20MG VIAL ![Compare how all Medicare Part D PDP plans in IN cover SOMAVERT 20MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SONATA 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SONATA 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SONATA 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SONATA 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD ![Compare how all Medicare Part D PDP plans in IN cover SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD ![Compare how all Medicare Part D PDP plans in IN cover SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD ![Compare how all Medicare Part D PDP plans in IN cover SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD ![Compare how all Medicare Part D PDP plans in IN cover SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTALOL HCL 120MG TABLET 100 BOT ![Compare how all Medicare Part D PDP plans in IN cover SOTALOL HCL 120MG TABLET 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTALOL HCL 160MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in IN cover SOTALOL HCL 160MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTALOL HCL 80MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SOTALOL HCL 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTALOL HCL TABLET 240MG ![Compare how all Medicare Part D PDP plans in IN cover SOTALOL HCL TABLET 240MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTRET 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SOTRET 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTRET 20MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SOTRET 20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTRET 30MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SOTRET 30MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SOTRET 40MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SOTRET 40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK ![Compare how all Medicare Part D PDP plans in IN cover SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SPIRONOLACTONE 100MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SPIRONOLACTONE 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in IN cover SPIRONOLACTONE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in IN cover SPIRONOLACTONE 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) ![Compare how all Medicare Part D PDP plans in IN cover SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SPRINTEC 0.25-0.035 TABLET ![Compare how all Medicare Part D PDP plans in IN cover SPRINTEC 0.25-0.035 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SPRYCEL 20MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SPRYCEL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SPRYCEL 50MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SPRYCEL 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SPRYCEL 70MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SPRYCEL 70MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SRONYX 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in IN cover SRONYX 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in IN cover SSD Cream 10g/1000g 85 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STAGESIC 5MG-500MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STAGESIC 5MG-500MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STARLIX 120MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover STARLIX 120MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | S |
STARLIX 60MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover STARLIX 60MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | S |
STAVUDINE CAPSULES 15MG 60 BOT ![Compare how all Medicare Part D PDP plans in IN cover STAVUDINE CAPSULES 15MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 20MG 60 BOT ![Compare how all Medicare Part D PDP plans in IN cover STAVUDINE CAPSULES 20MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STAVUDINE CAPSULES 30MG 60 BOT ![Compare how all Medicare Part D PDP plans in IN cover STAVUDINE CAPSULES 30MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STAVUDINE CAPSULES 40MG 60 BOT ![Compare how all Medicare Part D PDP plans in IN cover STAVUDINE CAPSULES 40MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STAVUDINE SOL 1MG/ML ![Compare how all Medicare Part D PDP plans in IN cover STAVUDINE SOL 1MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STELARA 45 MG/0.5 ML SYRINGE ![Compare how all Medicare Part D PDP plans in IN cover STELARA 45 MG/0.5 ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
STELARA 90 MG/ML SYRINGE ![Compare how all Medicare Part D PDP plans in IN cover STELARA 90 MG/ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON ![Compare how all Medicare Part D PDP plans in IN cover Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
STERILE WATER FOR IRRIGATION ![Compare how all Medicare Part D PDP plans in IN cover STERILE WATER FOR IRRIGATION .](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
STRATTERA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
STRATTERA 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
STRATTERA 18MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 18MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
STRATTERA 40MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
STRATTERA 60MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 60MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
STRATTERA 80MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover STRATTERA 80MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
STREPTOMYCIN FOR INJECTION 1GM/VIL ![Compare how all Medicare Part D PDP plans in IN cover STREPTOMYCIN FOR INJECTION 1GM/VIL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH ![Compare how all Medicare Part D PDP plans in IN cover Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SUBOXONE 2MG-0.5MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SUBOXONE 2MG-0.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH ![Compare how all Medicare Part D PDP plans in IN cover Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SUBOXONE 8MG-2MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SUBOXONE 8MG-2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SUCRAID 8500[iU]/mL ![Compare how all Medicare Part D PDP plans in IN cover SUCRAID 8500[iU]/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SUCRALFATE 1GM TABLET ![Compare how all Medicare Part D PDP plans in IN cover SUCRALFATE 1GM TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE 10% EYE OINTMENT ![Compare how all Medicare Part D PDP plans in IN cover SULFACETAMIDE 10% EYE OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT ![Compare how all Medicare Part D PDP plans in IN cover SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS ![Compare how all Medicare Part D PDP plans in IN cover SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFADIAZINE 500MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SULFADIAZINE 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in IN cover SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL ![Compare how all Medicare Part D PDP plans in IN cover SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) ![Compare how all Medicare Part D PDP plans in IN cover SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFASALAZINE 500MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SULFASALAZINE 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in IN cover SULFAZINE EC 500MG TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in IN cover SULINDAC 150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SULINDAC 200MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SULINDAC 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
SUMATRIPTAN ![Compare how all Medicare Part D PDP plans in IN cover SUMATRIPTAN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | Q:9 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE ![Compare how all Medicare Part D PDP plans in IN cover Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | Q:4 /30Days |
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD ![Compare how all Medicare Part D PDP plans in IN cover SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD ![Compare how all Medicare Part D PDP plans in IN cover SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | Q:12 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX ![Compare how all Medicare Part D PDP plans in IN cover SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | Q:12 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX ![Compare how all Medicare Part D PDP plans in IN cover SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.50 | $13.75 | Q:12 /30Days |
SURMONTIL 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SURMONTIL 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SURMONTIL 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SURMONTIL 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SUSTIVA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SUSTIVA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SUSTIVA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SUSTIVA 600MG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SUSTIVA 600MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SUTENT 12.5MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SUTENT 12.5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SUTENT 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SUTENT 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in IN cover SYLATRON 296 MCG KIT 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in IN cover SYLATRON 444 MCG KIT 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in IN cover SYLATRON 888 MCG KIT 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER ![Compare how all Medicare Part D PDP plans in IN cover SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL ![Compare how all Medicare Part D PDP plans in IN cover SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBYAX 12-25MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SYMBYAX 12-25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYMBYAX 12-50MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SYMBYAX 12-50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover Symbyax 25; 3mg/1; mg/1 30 CAPSULE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYMBYAX 6-25MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SYMBYAX 6-25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYMBYAX 6-50MG CAPSULE ![Compare how all Medicare Part D PDP plans in IN cover SYMBYAX 6-50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYMLIN 0.6MG/ML VIAL ![Compare how all Medicare Part D PDP plans in IN cover SYMLIN 0.6MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR ![Compare how all Medicare Part D PDP plans in IN cover SYMLINPEN 120 1000MCG/ML PEN INJECTOR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR ![Compare how all Medicare Part D PDP plans in IN cover SYMLINPEN 60 1000MCG/ML PEN INJECTOR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SYNAGIS 50MG/0.5ML VIAL ![Compare how all Medicare Part D PDP plans in IN cover SYNAGIS 50MG/0.5ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
SYNAREL 2MG/ML NASAL SPRAY ![Compare how all Medicare Part D PDP plans in IN cover SYNAREL 2MG/ML NASAL SPRAY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
30% | N/A | P |
SYNTHROID 100MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 112 MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 112 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 125MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Synthroid 137ug/1 90 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in IN cover Synthroid 137ug/1 90 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 150MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 150MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 175MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 200MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 25MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 300MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 50MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 75MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 75MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
SYNTHROID 88 MCG TABLET ![Compare how all Medicare Part D PDP plans in IN cover SYNTHROID 88 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$85.00 | $212.50 | None |