2013 Medicare Part D Plan Formulary Information |
BlueMedicare Regional PPO (Regional PPO) (R3332-001-0)
Benefit Details
|
The BlueMedicare Regional PPO (Regional PPO) (R3332-001-0) Formulary Drugs Starting with the Letter S in Statewide County, FL: CMS MA Region 9 which includes: FL
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Drugs Starting with Letter S
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Salagen 5mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Salagen 7.5mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SANCTURA TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
SANCTURA XR 60MG CAPSULE SR 24 HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
SANDIMMUNE 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
SANDIMMUNE 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 |
$95.00 | $285.00 | 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 |
$95.00 | $285.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SECTRAL 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SECTRAL 400MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SELEGILINE HCL 5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
SENSIPAR 60MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SENSIPAR 90MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
SEPTRA DS TABLET 800-160 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SEROQUEL 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
SEROQUEL 200MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
SEROQUEL 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
SEROQUEL 300MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
SEROQUEL 400MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
SEROQUEL 50MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:30 /30Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:30 /30Days |
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:300 /30Days |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
sF Rowasa 4g/60mL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILDENAFIL 20 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:90 /30Days |
SILVADENE 1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SILVER SULFADIAZINE 1% CRM |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SIMULECT 20MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:45 /30Days |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:45 /30Days |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:45 /30Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:30 /30Days |
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SINGULAIR 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
SINGULAIR 4 MG TABLET CHEW |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
SINGULAIR 4MG GRANULES |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
SINGULAIR 5 MG TABLET CHEW |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SODIUM PHENYLBUTYRATE POWDER |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
sodium polystyrene sulf pwd |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SOLARAZE 3% GEL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
SOLTAMOX 10 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SOLU MEDROL FOR INJECTION 40 MG/ML |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SOLU MEDROL FOR INJECTION 500 MG/ML |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SOLU-MEDROL 2000MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Specialty Tier |
33% | 33% | P |
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% | 33% | P |
SOMAVERT 10MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 15MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 20MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SONATA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
SONATA 5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
SORIATANE 17.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
SORIATANE CAPSULES |
5 |
Specialty Tier |
33% | 33% | None |
SORIATANE CAPSULES |
5 |
Specialty Tier |
33% | 33% | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SPORANOX 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SPORANOX 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SRONYX 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
STAGESIC 5MG-500MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:240 /30Days |
STALEVO 100 TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
STALEVO 125/200 MG/MG TABLETS |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STALEVO 150 TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
STALEVO 200 50-200-200 TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
STALEVO 50 TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
STARLIX 120MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
STARLIX 60MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:180 /30Days |
STAVUDINE 1 MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:2400 /30Days |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STERILE WATER FOR IRRIGATION |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY in 1 CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:84 /28Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STRIBILD TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
STROMECTOL 3MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 |
$95.00 | $285.00 | Q:90 /30Days |
SUBOXONE 2MG-0.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBOXONE 8MG-2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
SUCRALFATE 1GM TABLET |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SULAR 17MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SULAR 34MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SULAR 8.5MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SULFADIAZINE 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
SULFASALAZINE 500MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SULINDAC 150MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SULINDAC 200MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Sumatriptan 6 mg/0.5 ml vial |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:18 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX |
1 |
Preferred Generic |
$6.00 | $0.00 | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 400 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SURMONTIL 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUSTIVA 200MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
SUSTIVA 50MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
SUSTIVA 600MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:90 /30Days |
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:10 /30Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:10 /30Days |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
SYNERCID 500MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNTHROID 100MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 112 MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 125MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 150MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 175MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 200MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 25MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 300MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 50MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 75MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNTHROID 88 MCG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYPRINE 250MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | 33% | None |