2013 Medicare Part D Plan Formulary Information |
Humana Gold Plus H1036-146 (HMO) (H1036-146-0)
Benefit Details
|
The Humana Gold Plus H1036-146 (HMO) (H1036-146-0) Formulary Drugs Starting with the Letter S in SEMINOLE County, FL: CMS MA Region 9 which includes: FL
|
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 |
Safyral 3 BLISTER PACK in 1 PACKAGE / 1 KIT in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
Saizen 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P |
SAIZEN CLICKEASY 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P |
Salagen 5mg/1 |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
Salagen 7.5mg/1 |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SANCTURA TABLETS |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SANCTURA XR 60MG CAPSULE SR 24 HR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:4 /30Days |
SANDOSTATIN 0.05MG/ML AMPUL |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SANDOSTATIN 0.2MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
SANDOSTATIN 1MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
SANDOSTATIN LAR 10MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
SANDOSTATIN LAR 20MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
SANDOSTATIN LAR 30MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:60 /30Days |
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:60 /30Days |
SARAFEM 10mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK in 1 CARTON / 7 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK in 1 CARTON / 7 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:91 /90Days |
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:91 /90Days |
SECTRAL 200MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SECTRAL 400MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SELEGILINE HCL 5 MG TABLET |
3 |
Preferred Brand |
$20.00 | $50.00 | None |
SELEGILINE HCL 5MG CAPSULE |
3 |
Preferred Brand |
$20.00 | $50.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | Q:240 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
SEMPREX-D 8 MG-60 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SENSIPAR 60MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
SEPTRA DS TABLET 800-160 |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:90 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:60 /30Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:540 /30Days |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
sF Rowasa 4g/60mL |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:1800 /30Days |
Signifor .3 mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
Signifor .6 mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SILDENAFIL 20 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:90 /30Days |
Silenor 3mg/1 30 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
Silenor 6mg/1 30 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
SILVADENE 1% CREAM |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SILVER SULFADIAZINE 1% CRM |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Simcor ER 1000; 20mg/1; mg 90 FILM COATED TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
SIMCOR TABLETS EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
SIMCOR TABLETS EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
SIMULECT 20MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
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 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SINGULAIR 10 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | S Q:30 /30Days |
SINGULAIR 4 MG TABLET CHEW |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | S Q:30 /30Days |
SINGULAIR 4MG GRANULES |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | S Q:30 /30Days |
SINGULAIR 5 MG TABLET CHEW |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | S Q:30 /30Days |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:68 /28Days |
SKELID 200MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Sodium Chloride 3g/100mL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SODIUM LACTATE 1/6MOLAR INJ |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SODIUM PHENYLBUTYRATE POWDER |
5 |
Specialty Tier |
33% | N/A | None |
sodium polystyrene sulf pwd |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SOLARAZE 3% GEL |
3 |
Preferred Brand |
$20.00 | $50.00 | None |
Solodyn 105mg/1 |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:30 /30Days |
Solodyn 55mg/1 |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Solodyn 80mg/1 |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:30 /30Days |
SOLODYN ER 65 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SOLTAMOX 10 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:600 /30Days |
SOLU CORTEF INJECTION |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SOLU CORTEF INJECTION 100 MG/VIAL |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SOLU MEDROL FOR INJECTION 40 MG/ML |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SOLU MEDROL FOR INJECTION 500 MG/ML |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SOLU-MEDROL 2000MG VIAL |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
Soma 250mg 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:120 /30Days |
SOMA TABLETS |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
SOMAVERT 10MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SOMAVERT 15MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SOMAVERT 20MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SORIATANE 17.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
SORIATANE CAPSULES |
5 |
Specialty Tier |
33% | N/A | None |
SORIATANE CAPSULES |
5 |
Specialty Tier |
33% | N/A | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SOTALOL HYDROCHLORIDE INJECTION 15MG/ML |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SPECTRACEF 400 MG DOSE PACK TB |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SPECTRACEF TABLETS 200 MG |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:30 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SRONYX 0.1-0.02 TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAGESIC 5MG-500MG CAPSULE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:240 /30Days |
STAVUDINE 1 MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:2400 /30Days |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
STAVZOR 125MG CPDR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
STAVZOR 250MG CPDR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
STAVZOR 500MG CPDR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:3 /84Days |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:3 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P |
STERILE WATER FOR IRRIGATION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY in 1 CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:84 /28Days |
STRATTERA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
STRATTERA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
STRATTERA 18MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
STRATTERA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
STRATTERA 40MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:60 /30Days |
STRATTERA 60MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
STRATTERA 80MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Striant 30mg/1 6 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
STROMECTOL 3MG TABLET |
3 |
Preferred Brand |
$20.00 | $50.00 | None |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:60 /30Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:90 /30Days |
SUBOXONE 2MG-0.5MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:90 /30Days |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:90 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:90 /30Days |
SUBOXONE 8MG-2MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:90 /30Days |
SUCRALFATE 1GM TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFADIAZINE 500MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMYLON 50G PACKET |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFASALAZINE 500MG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SULINDAC 150MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SULINDAC 200MG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:6 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:6 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:9 /30Days |
SUPREP bowel prep 1.6; 3.13; 17.5g/mL; g/mL; g/mL 2 BOTTLE, PLASTIC in 1 CARTON / 177.4 mL in 1 BOT |
3 |
Preferred Brand |
$20.00 | $50.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SURMONTIL 25MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P |
SUSTIVA 200MG CAPSULE |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days |
SUSTIVA 50MG CAPSULE |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:480 /30Days |
SUSTIVA 600MG TABLET |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:30 /30Days |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:11 /30Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:11 /30Days |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:11 /30Days |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:11 /30Days |
SYNALGOS DC CAPSULES 16;356.4;MG;MG;MG; |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:330 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | None |
SYNERCID 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
SYNTHROID 100MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 112 MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 125MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Synthroid 137ug/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 150MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 175MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 200MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 25MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 300MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 50MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 75MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYNTHROID 88 MCG TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
SYPRINE 250MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None |