2012 Medicare Part D Plan Formulary Information |
Central Health Medicare Plan (HMO) (H5649-001-0)
Benefit Details
|
The Central Health Medicare Plan (HMO) (H5649-001-0) Formulary Drugs Starting with the Letter S in Los Angeles County, CA: CMS MA Region 24 which includes: CA
|
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 |
5 |
Tier 5 |
33% | 33% | P |
SAIZEN CLICKEASY 1 KIT in 1 CARTON |
5 |
Tier 5 |
33% | 33% | P |
SANDIMMUNE 100MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Tier 3 |
$25.00 | $50.00 | P |
SANDIMMUNE 25MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
3 |
Tier 3 |
$25.00 | $50.00 | P |
SANDOSTATIN LAR 10MG KIT |
5 |
Tier 5 |
33% | 33% | P Q:1 /28Days |
SANDOSTATIN LAR 20MG KIT |
5 |
Tier 5 |
33% | 33% | P Q:2 /28Days |
SANDOSTATIN LAR 30MG KIT |
5 |
Tier 5 |
33% | 33% | P Q:1 /28Days |
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK |
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 |
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SELEGILINE HCL 5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Selegiline Hydrochloride 5mg/1 60 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
5 |
Tier 5 |
33% | 33% | None |
SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
5 |
Tier 5 |
33% | 33% | None |
SENSIPAR 30MG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SENSIPAR 60MG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SENSIPAR 90MG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 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 |
SEROQUEL 100MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:120 /30Days |
SEROQUEL 200MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:90 /30Days |
SEROQUEL 25MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:120 /30Days |
SEROQUEL 300MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:90 /30Days |
SEROQUEL 400MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL 50MG TABLET (100 CT) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:120 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
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 |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
5 |
Tier 5 |
33% | 33% | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
5 |
Tier 5 |
33% | 33% | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:300 /30Days |
SILVER SULFADIAZINE 1% CRM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
SIMCOR TABLETS EXTENDED RELEASE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
SIMCOR TABLETS EXTENDED RELEASE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Tier 5 |
33% | 33% | P |
SIMULECT 20MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$5.00 | $10.00 | Q:30 /30Days |
SIMVASTATIN 20MG TABLET 10000 BOT |
2 |
Tier 2 |
$5.00 | $10.00 | Q:30 /30Days |
SIMVASTATIN 40MG TABLET (500 CT) |
2 |
Tier 2 |
$5.00 | $10.00 | Q:30 /30Days |
Simvastatin 5mg/1 |
2 |
Tier 2 |
$5.00 | $10.00 | Q:30 /30Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
2 |
Tier 2 |
$5.00 | $10.00 | Q:30 /30Days |
SINGULAIR 10MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SINGULAIR 4MG GRANULES |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SINGULAIR 4MG TABLET CHEW |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /30Days |
SINGULAIR 5MG TABLET CHEW |
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 |
SOD POLY SUL SUS 15GM/60 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SODIUM BICARB INJ 7.5% |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SODIUM CHLORIDE 0.45% TUBEX |
4 |
Tier 4 |
$50.00 | $100.00 | P |
Sodium Chloride 3g/100mL |
4 |
Tier 4 |
$50.00 | $100.00 | P |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SODIUM CHLORIDE INJECTION USP 5% |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SODIUM CL 2.5 MEQ/ML VIAL |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SOLARAZE 3% GEL |
3 |
Tier 3 |
$25.00 | $50.00 | P Q:50 /1Days |
SOLIA 0.15-0.03 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
5 |
Tier 5 |
33% | 33% | P |
SOMAVERT 10MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
SOMAVERT 15MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
SOMAVERT 20MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SOTALOL HCL 120MG TABLET 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SOTALOL HCL 160MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SOTALOL HCL 80MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL HCL TABLET 240MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Tier 3 |
$25.00 | $50.00 | Q:90 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE |
5 |
Tier 5 |
33% | 33% | None |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SRONYX 0.1-0.02 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STAGESIC 5MG-500MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
STALEVO 100 TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
STALEVO 125/200 MG/MG TABLETS |
3 |
Tier 3 |
$25.00 | $50.00 | None |
STALEVO 150 TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
3 |
Tier 3 |
$25.00 | $50.00 | None |
STALEVO 200 50-200-200 TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
STALEVO 50 TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STAVUDINE SOL 1MG/ML |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STAVZOR 125MG CPDR |
4 |
Tier 4 |
$50.00 | $100.00 | None |
STAVZOR 250MG CPDR |
4 |
Tier 4 |
$50.00 | $100.00 | None |
STAVZOR 500MG CPDR |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON |
5 |
Tier 5 |
33% | 33% | P |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY in 1 CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Tier 4 |
$50.00 | $100.00 | None |
STRATTERA 100MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
STRATTERA 10MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
STRATTERA 18MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 25MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
STRATTERA 40MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
STRATTERA 60MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
STRATTERA 80MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:60 /30Days |
Striant 30mg/1 6 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK |
4 |
Tier 4 |
$50.00 | $100.00 | P |
STROMECTOL 3MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Tier 4 |
$50.00 | $100.00 | Q:90 /30Days |
SUBOXONE 2MG-0.5MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:90 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Tier 4 |
$50.00 | $100.00 | Q:90 /30Days |
SUBOXONE 8MG-2MG TABLET |
4 |
Tier 4 |
$50.00 | $100.00 | Q:90 /30Days |
SUCRALFATE 1GM TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFADIAZINE 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
4 |
Tier 4 |
$50.00 | $100.00 | P |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFAMYLON 50G PACKET |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | 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 |
$0.00 | $0.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULINDAC 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SUMATRIPTAN |
2 |
Tier 2 |
$5.00 | $10.00 | Q:6 /30Days |
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD |
2 |
Tier 2 |
$5.00 | $10.00 | Q:6 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Tier 2 |
$5.00 | $10.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
2 |
Tier 2 |
$5.00 | $10.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
2 |
Tier 2 |
$5.00 | $10.00 | Q:9 /30Days |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Tier 4 |
$50.00 | $100.00 | None |
SUSTIVA 200MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 50MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SUSTIVA 600MG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE |
5 |
Tier 5 |
33% | 33% | None |
SUTENT 50MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON |
5 |
Tier 5 |
33% | 33% | Q:1 /28Days |
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON |
5 |
Tier 5 |
33% | 33% | Q:1 /28Days |
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON |
5 |
Tier 5 |
33% | 33% | Q:1 /28Days |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
4 |
Tier 4 |
$50.00 | $100.00 | Q:10 /30Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
4 |
Tier 4 |
$50.00 | $100.00 | Q:7 /30Days |
SYMBYAX 12-25MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBYAX 12-50MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:30 /30Days |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:30 /30Days |
SYMBYAX 6-25MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:30 /30Days |
SYMBYAX 6-50MG CAPSULE |
3 |
Tier 3 |
$25.00 | $50.00 | Q:30 /30Days |
SYMLIN 0.6MG/ML VIAL |
4 |
Tier 4 |
$50.00 | $100.00 | Q:20 /30Days |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
4 |
Tier 4 |
$50.00 | $100.00 | Q:11 /30Days |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
4 |
Tier 4 |
$50.00 | $100.00 | Q:11 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Tier 5 |
33% | 33% | P |
SYNTHROID 100MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 112 MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 125MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Synthroid 137ug/1 90 TABLET in 1 BOTTLE |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 150MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 175MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 200MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 25MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 300MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 50MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 75MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYNTHROID 88 MCG TABLET |
3 |
Tier 3 |
$25.00 | $50.00 | None |
SYPRINE 250MG CAPSULE (100 CT) |
4 |
Tier 4 |
$50.00 | $100.00 | None |