2012 Medicare Part D Plan Formulary Information |
Triple-S FarmaMed Plus (PDP) (S5907-002-0)
Benefit Details
|
The Triple-S FarmaMed Plus (PDP) (S5907-002-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 38 which includes: PR
|
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 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SAIZEN CLICKEASY 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Salagen 5mg/1 |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Salagen 7.5mg/1 |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SANDIMMUNE 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SANDIMMUNE 25MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SANDIMMUNE 50MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SANDOSTATIN 0.05MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SANDOSTATIN 0.2MG/ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDOSTATIN 1MG/ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SANDOSTATIN LAR 10MG KIT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SANDOSTATIN LAR 20MG KIT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SANDOSTATIN LAR 30MG KIT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SECTRAL 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SECTRAL 400MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
4 |
Specialty Tier Drugs |
25% | 25% | None |
SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
4 |
Specialty Tier Drugs |
25% | 25% | None |
SENSIPAR 30MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
SENSIPAR 60MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
SENSIPAR 90MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
SEPTRA 80/400 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEPTRA DS TABLET 800-160 |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEREVENT DIS AER 50MCG |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEROQUEL 100MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 200MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEROQUEL 25MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEROQUEL 300MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEROQUEL 400MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SEROQUEL 50MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
SILVADENE 1% CREAM |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SIMVASTATIN 20MG TABLET 10000 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Simvastatin 5mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
SINEMET 10; 100mg/1; mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SINEMET 25; 250mg/1; mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SINGULAIR 10MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | S |
SINGULAIR 4MG GRANULES |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | S |
SINGULAIR 4MG TABLET CHEW |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | S |
SINGULAIR 5MG TABLET CHEW |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | S |
SOD POLY SUL SUS 15GM/60 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
SOLARAZE 3% GEL |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SOLU CORTEF INJECTION |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SOLU CORTEF INJECTION 100 MG/VIAL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SOLU MEDROL FOR INJECTION 40 MG/ML |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SOMATULINE 60 MG/0.2 ML SYRING |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SOMAVERT 10MG VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SOMAVERT 15MG VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SOMAVERT 20MG VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SONATA 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
SONATA 5MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
SORIATANE 17.5 MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SORIATANE CAPSULES |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SORIATANE CAPSULES |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SOTALOL HCL 80MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SOTRET 10MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SOTRET 20MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTRET 30MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SOTRET 40MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SPIRONOLACTONE 100MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SPORANOX 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SPRYCEL 20MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 50MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SPRYCEL 70MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
STALEVO 100 TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
STALEVO 125/200 MG/MG TABLETS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
STALEVO 150 TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
STALEVO 200 50-200-200 TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
STALEVO 50 TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
STARLIX 120MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
STARLIX 60MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
STAVUDINE SOL 1MG/ML |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY in 1 CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
STRATTERA 100MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
STRATTERA 10MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
STRATTERA 18MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
STRATTERA 25MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 40MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
STRATTERA 60MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
STRATTERA 80MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P |
STROMECTOL 3MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SUBOXONE 2MG-0.5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SUBOXONE 8MG-2MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SUBUTEX 2MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SUBUTEX 8MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SUCRALFATE 1GM TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFADIAZINE 500MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SULINDAC 200MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SUMATRIPTAN |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
SURMONTIL 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SURMONTIL 25MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SUSTIVA 200MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SUSTIVA 50MG CAPSULE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SUSTIVA 600MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SUTENT 12.5MG CAPSULE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 50MG CAPSULE |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SYMBYAX 12-25MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SYMBYAX 12-50MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SYMBYAX 6-25MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
SYMBYAX 6-50MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMLIN 0.6MG/ML VIAL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
SYNAGIS 50MG/0.5ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Specialty Tier Drugs |
25% | 25% | None |
SYNTHROID 100MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 112 MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 125MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Synthroid 137ug/1 90 TABLET in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 150MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 175MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 200MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 25MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 300MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 50MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 75MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
SYNTHROID 88 MCG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |