Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Gold (PDP) (S5596-035-0) Benefit Details
The Blue Cross MedicareRx Gold (PDP) (S5596-035-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter S Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter S Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Salagen 5mg/1	4	Non-Preferred Brand	$90.00	$225.00	None
Salagen 7.5mg/1	4	Non-Preferred Brand	$90.00	$225.00	None
SANCTURA TABLETS	4	Non-Preferred Brand	$90.00	$225.00	S Q:60 /30Days
SANCTURA XR 60MG CAPSULE SR 24 HR	4	Non-Preferred Brand	$90.00	$225.00	S Q:30 /30Days
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN	6	Specialty Tier	33%	N/A	P Q:4 /28Days
SANDIMMUNE 100MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P
SANDIMMUNE 100MG/ML TUBEX	4	Non-Preferred Brand	$90.00	$225.00	P
SANDIMMUNE 25MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P
SANDIMMUNE 50MG/ML AMPUL	5	Injectable Drugs	$95.00	$237.50	P
SANDOSTATIN 0.05MG/ML AMPUL	5	Injectable Drugs	$95.00	$237.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SANDOSTATIN 0.2MG/ML VIAL	6	Specialty Tier	33%	N/A	P
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE	6	Specialty Tier	33%	N/A	P
SANDOSTATIN 1MG/ML VIAL	6	Specialty Tier	33%	N/A	P
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE	6	Specialty Tier	33%	N/A	P
SANDOSTATIN LAR 10MG KIT	6	Specialty Tier	33%	N/A	P
SANDOSTATIN LAR 20MG KIT	6	Specialty Tier	33%	N/A	P
SANDOSTATIN LAR 30MG KIT	6	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	$90.00	$225.00	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	$90.00	$225.00	Q:120 /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	$90.00	$225.00	Q:240 /30Days
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK in 1 CARTON / 7 TABLET in 1 BLISTER PACK	4	Non-Preferred Brand	$90.00	$225.00	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SAVELLA TABLETS 100MG 60 COUNT BOT	3	Preferred Brand	$45.00	$112.50	Q:60 /30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT	3	Preferred Brand	$45.00	$112.50	Q:480 /30Days
SAVELLA TABLETS 25MG 60 COUNT BOT	3	Preferred Brand	$45.00	$112.50	Q:240 /30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM	3	Preferred Brand	$45.00	$112.50	Q:1 /365Days
SAVELLA TALBETS 50MG 60 COUNT BOT	3	Preferred Brand	$45.00	$112.50	Q:120 /30Days
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS	4	Non-Preferred Brand	$90.00	$225.00	None
SECTRAL 200MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
SECTRAL 400MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
SELEGILINE HCL 5 MG TABLET	2	Non-Preferred Generic	$7.00	$10.50	None
SELEGILINE HCL 5MG CAPSULE	2	Non-Preferred Generic	$7.00	$10.50	None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE	2	Non-Preferred Generic	$7.00	$10.50	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	6	Specialty Tier	33%	N/A	None
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE	6	Specialty Tier	33%	N/A	None
SENSIPAR 30MG TABLET	3	Preferred Brand	$45.00	$112.50	Q:60 /30Days
SENSIPAR 60MG TABLET	6	Specialty Tier	33%	N/A	Q:60 /30Days
SENSIPAR 90MG TABLET	6	Specialty Tier	33%	N/A	Q:120 /30Days
SEPTRA DS TABLET 800-160	4	Non-Preferred Brand	$90.00	$225.00	None
SEREVENT DIS AER 50MCG	3	Preferred Brand	$45.00	$112.50	Q:60 /30Days
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
SEROQUEL 100MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	Q:240 /30Days
SEROQUEL 200MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	Q:120 /30Days
SEROQUEL 25MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	Q:960 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SEROQUEL 300MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	Q:120 /30Days
SEROQUEL 400MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	Q:120 /30Days
SEROQUEL 50MG TABLET (100 CT)	4	Non-Preferred Brand	$90.00	$225.00	Q:480 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN	3	Preferred Brand	$45.00	$112.50	Q:160 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN	3	Preferred Brand	$45.00	$112.50	Q:120 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN	3	Preferred Brand	$45.00	$112.50	Q:120 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN	3	Preferred Brand	$45.00	$112.50	Q:480 /30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT	3	Preferred Brand	$45.00	$112.50	Q:90 /30Days
SERTRALINE HCL 100MG TABLET (30 CT)	2	Non-Preferred Generic	$7.00	$10.50	Q:90 /30Days
SERTRALINE HCL 25 MG TABLET	2	Non-Preferred Generic	$7.00	$10.50	Q:240 /30Days
SERTRALINE HCL 50MG TABLET (30 CT)	2	Non-Preferred Generic	$7.00	$10.50	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE	2	Non-Preferred Generic	$7.00	$10.50	Q:300 /30Days
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]	3	Preferred Brand	$45.00	$112.50	None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]	3	Preferred Brand	$45.00	$112.50	None
SILDENAFIL 20 MG TABLET	6	Specialty Tier	33%	N/A	P Q:90 /30Days
SILVADENE 1% CREAM	4	Non-Preferred Brand	$90.00	$225.00	None
SILVER SULFADIAZINE 1% CRM	2	Non-Preferred Generic	$7.00	$10.50	None
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR	3	Preferred Brand	$45.00	$112.50	Q:60 /30Days
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR	3	Preferred Brand	$45.00	$112.50	Q:60 /30Days
Simcor ER 1000; 20mg/1; mg 90 FILM COATED TABLET BOTTLE	3	Preferred Brand	$45.00	$112.50	Q:60 /30Days
SIMCOR TABLETS EXTENDED RELEASE	3	Preferred Brand	$45.00	$112.50	Q:30 /30Days
SIMCOR TABLETS EXTENDED RELEASE	3	Preferred Brand	$45.00	$112.50	Q:30 /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	6	Specialty Tier	33%	N/A	P Q:1 /28Days
SIMULECT 20MG VIAL	6	Specialty Tier	33%	N/A	P
SIMVASTATIN 10 MG TABLET	1	Preferred Generic	$2.00	$3.00	Q:30 /30Days
SIMVASTATIN 20 MG TABLET	1	Preferred Generic	$2.00	$3.00	Q:30 /30Days
SIMVASTATIN 40MG TABLET (500 CT)	1	Preferred Generic	$2.00	$3.00	Q:30 /30Days
SIMVASTATIN 5 MG TABLET	1	Preferred Generic	$2.00	$3.00	Q:30 /30Days
SIMVASTATIN 80MG TABLET (1000 CT)	1	Preferred Generic	$2.00	$3.00	Q:30 /30Days
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	$90.00	$225.00	S
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	$90.00	$225.00	S
SINEMET 25; 250mg/1; mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	$90.00	$225.00	S
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$90.00	$225.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$90.00	$225.00	S
SINGULAIR 10 MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	Q:30 /30Days
SINGULAIR 4 MG TABLET CHEW	4	Non-Preferred Brand	$90.00	$225.00	Q:30 /30Days
SINGULAIR 4MG GRANULES	4	Non-Preferred Brand	$90.00	$225.00	Q:30 /30Days
SINGULAIR 5 MG TABLET CHEW	4	Non-Preferred Brand	$90.00	$225.00	Q:30 /30Days
SKELID 200MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	None
SODIUM CHLORIDE 0.45% TUBEX	5	Injectable Drugs	$95.00	$237.50	None
Sodium Chloride 3g/100mL	5	Injectable Drugs	$95.00	$237.50	None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC	5	Injectable Drugs	$95.00	$237.50	None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG	5	Injectable Drugs	$95.00	$237.50	None
SODIUM CHLORIDE INJECTION USP 5%	5	Injectable Drugs	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SODIUM CL 2.5 MEQ/ML VIAL	5	Injectable Drugs	$95.00	$237.50	None
SODIUM LACTATE 1/6MOLAR INJ	5	Injectable Drugs	$95.00	$237.50	None
SODIUM LACTATE 5 MEQ/ML VIAL	5	Injectable Drugs	$95.00	$237.50	None
SODIUM PHENYLBUTYRATE POWDER	6	Specialty Tier	33%	N/A	P
sodium polystyrene sulf pwd	3	Preferred Brand	$45.00	$112.50	None
SOLARAZE 3% GEL	3	Preferred Brand	$45.00	$112.50	P Q:100 /30Days
SOLTAMOX 10 MG/5 ML SOLN	4	Non-Preferred Brand	$90.00	$225.00	None
SOLU CORTEF INJECTION	5	Injectable Drugs	$95.00	$237.50	None
SOLU CORTEF INJECTION 100 MG/VIAL	5	Injectable Drugs	$95.00	$237.50	None
SOLU MEDROL FOR INJECTION 40 MG/ML	5	Injectable Drugs	$95.00	$237.50	None
SOLU MEDROL FOR INJECTION 500 MG/ML	5	Injectable Drugs	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY	5	Injectable Drugs	$95.00	$237.50	None
SOLU-MEDROL 2000MG VIAL	5	Injectable Drugs	$95.00	$237.50	None
SOMAVERT 10MG VIAL	6	Specialty Tier	33%	N/A	P
SOMAVERT 15MG VIAL	6	Specialty Tier	33%	N/A	P
SOMAVERT 20MG VIAL	6	Specialty Tier	33%	N/A	P
SORIATANE 17.5 MG CAPSULE	6	Specialty Tier	33%	N/A	None
SORIATANE CAPSULES	6	Specialty Tier	33%	N/A	None
SORIATANE CAPSULES	6	Specialty Tier	33%	N/A	None
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD	2	Non-Preferred Generic	$7.00	$10.50	None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD	2	Non-Preferred Generic	$7.00	$10.50	None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD	2	Non-Preferred Generic	$7.00	$10.50	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	2	Non-Preferred Generic	$7.00	$10.50	None
SOTALOL HCL TABLET 240MG	2	Non-Preferred Generic	$7.00	$10.50	None
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$7.00	$10.50	None
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$7.00	$10.50	None
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$7.00	$10.50	None
SPECTRACEF 400 MG DOSE PACK TB	4	Non-Preferred Brand	$90.00	$225.00	None
SPECTRACEF TABLETS 200 MG	4	Non-Preferred Brand	$90.00	$225.00	None
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK	3	Preferred Brand	$45.00	$112.50	Q:30 /30Days
SPIRONOLACTONE 100MG TABLET	1	Preferred Generic	$2.00	$3.00	None
SPIRONOLACTONE 25MG TABLET (100 CT)	1	Preferred Generic	$2.00	$3.00	None
SPIRONOLACTONE 50MG TABLET (100 CT)	1	Preferred Generic	$2.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)	2	Non-Preferred Generic	$7.00	$10.50	None
SPORANOX 100MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P
SPORANOX 100MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P
SPORANOX 10MG/ML SOLUTION	4	Non-Preferred Brand	$90.00	$225.00	None
SPRINTEC 0.25-0.035 TABLET	3	Preferred Brand	$45.00	$112.50	None
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE	6	Specialty Tier	33%	N/A	P
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE	6	Specialty Tier	33%	N/A	P
SPRYCEL 20MG TABLET	6	Specialty Tier	33%	N/A	P
SPRYCEL 50MG TABLET	6	Specialty Tier	33%	N/A	P
SPRYCEL 70MG TABLET	6	Specialty Tier	33%	N/A	P
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE	6	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SRONYX 0.1-0.02 TABLET	3	Preferred Brand	$45.00	$112.50	None
SSD Cream 10g/1000g 85 g in 1 TUBE	2	Non-Preferred Generic	$7.00	$10.50	None
STAGESIC 5MG-500MG CAPSULE	2	Non-Preferred Generic	$7.00	$10.50	Q:240 /30Days
STALEVO 100 TABLET	3	Preferred Brand	$45.00	$112.50	None
STALEVO 125/200 MG/MG TABLETS	3	Preferred Brand	$45.00	$112.50	None
STALEVO 150 TABLET	3	Preferred Brand	$45.00	$112.50	None
STALEVO 18.75/75 MG/MG TABLETS	3	Preferred Brand	$45.00	$112.50	None
STALEVO 200 50-200-200 TABLET	3	Preferred Brand	$45.00	$112.50	None
STALEVO 50 TABLET	3	Preferred Brand	$45.00	$112.50	None
STARLIX 120MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	None
STARLIX 60MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STAVUDINE 1 MG/ML SOLUTION	2	Non-Preferred Generic	$7.00	$10.50	None
STAVUDINE CAPSULES 15MG 60 BOT	2	Non-Preferred Generic	$7.00	$10.50	None
STAVUDINE CAPSULES 20MG 60 BOT	2	Non-Preferred Generic	$7.00	$10.50	None
STAVUDINE CAPSULES 30MG 60 BOT	2	Non-Preferred Generic	$7.00	$10.50	None
STAVUDINE CAPSULES 40MG 60 BOT	2	Non-Preferred Generic	$7.00	$10.50	None
STELARA 45 MG/0.5 ML SYRINGE	6	Specialty Tier	33%	N/A	P Q:1 /28Days
STELARA 90 MG/ML SYRINGE	6	Specialty Tier	33%	N/A	P Q:1 /28Days
STERILE WATER FOR IRRIGATION	5	Injectable Drugs	$95.00	$237.50	None
Stimate 1.5mg/mL 1 BOTTLE, SPRAY in 1 CARTON / 2.5 mL in 1 BOTTLE, SPRAY	4	Non-Preferred Brand	$90.00	$225.00	None
STIVARGA 40 MG TABLET	6	Specialty Tier	33%	N/A	P
STRATTERA 100MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STRATTERA 10MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:60 /30Days
STRATTERA 18MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:60 /30Days
STRATTERA 25MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:60 /30Days
STRATTERA 40MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:60 /30Days
STRATTERA 60MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:30 /30Days
STRATTERA 80MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	P Q:30 /30Days
STREPTOMYCIN FOR INJECTION 1GM/VIL	5	Injectable Drugs	$95.00	$237.50	None
STRIBILD TABLET	6	Specialty Tier	33%	N/A	None
STROMECTOL 3MG TABLET	3	Preferred Brand	$45.00	$112.50	None
SUBOXONE 12 MG-3 MG SL FILM	3	Preferred Brand	$45.00	$112.50	P Q:60 /30Days
Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH	3	Preferred Brand	$45.00	$112.50	P Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUBOXONE 2MG-0.5MG TABLET	3	Preferred Brand	$45.00	$112.50	P Q:360 /30Days
SUBOXONE 4 MG-1 MG SL FILM	3	Preferred Brand	$45.00	$112.50	P Q:180 /30Days
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH	3	Preferred Brand	$45.00	$112.50	P Q:90 /30Days
SUBOXONE 8MG-2MG TABLET	3	Preferred Brand	$45.00	$112.50	P Q:90 /30Days
SUCRALFATE 1GM TABLET	2	Non-Preferred Generic	$7.00	$10.50	None
SULFACETAMIDE 10% EYE OINTMENT	2	Non-Preferred Generic	$7.00	$10.50	None
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE	2	Non-Preferred Generic	$7.00	$10.50	None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT	2	Non-Preferred Generic	$7.00	$10.50	None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS	2	Non-Preferred Generic	$7.00	$10.50	None
SULFADIAZINE 500MG TABLET	3	Preferred Brand	$45.00	$112.50	None
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE	2	Non-Preferred Generic	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)	2	Non-Preferred Generic	$7.00	$10.50	None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL	5	Injectable Drugs	$95.00	$237.50	None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)	2	Non-Preferred Generic	$7.00	$10.50	None
SULFAMYLON 50G PACKET	4	Non-Preferred Brand	$90.00	$225.00	None
SULFAMYLON CREAM 85GM 4 OZ TUBE	4	Non-Preferred Brand	$90.00	$225.00	None
SULFASALAZINE 500MG TABLET	1	Preferred Generic	$2.00	$3.00	None
SULFAZINE EC 500MG TABLET DELAYED RELEASE	2	Non-Preferred Generic	$7.00	$10.50	None
SULINDAC 150MG TABLET (100 CT)	2	Non-Preferred Generic	$7.00	$10.50	None
SULINDAC 200MG TABLET	2	Non-Preferred Generic	$7.00	$10.50	None
Sumatriptan 6 mg/0.5 ml vial	5	Injectable Drugs	$95.00	$237.50	Q:4 /30Days
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE	5	Injectable Drugs	$95.00	$237.50	Q:4 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD	3	Preferred Brand	$45.00	$112.50	Q:9 /30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX	3	Preferred Brand	$45.00	$112.50	Q:9 /30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX	3	Preferred Brand	$45.00	$112.50	Q:9 /30Days
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT	4	Non-Preferred Brand	$90.00	$225.00	None
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL	4	Non-Preferred Brand	$90.00	$225.00	None
SUPRAX 400 MG TABLET	4	Non-Preferred Brand	$90.00	$225.00	None
SUPRAX 500 MG/5 ML SUSPENSION	4	Non-Preferred Brand	$90.00	$225.00	None
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	4	Non-Preferred Brand	$90.00	$225.00	None
SURMONTIL 100MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
SURMONTIL 25MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE	4	Non-Preferred Brand	$90.00	$225.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUSTIVA 200MG CAPSULE	3	Preferred Brand	$45.00	$112.50	None
SUSTIVA 50MG CAPSULE	3	Preferred Brand	$45.00	$112.50	None
SUSTIVA 600MG TABLET	3	Preferred Brand	$45.00	$112.50	None
SUTENT 12.5MG CAPSULE	6	Specialty Tier	33%	N/A	P
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE	6	Specialty Tier	33%	N/A	P
SUTENT 50MG CAPSULE	6	Specialty Tier	33%	N/A	P
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON	6	Specialty Tier	33%	N/A	P
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON	6	Specialty Tier	33%	N/A	P
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON	6	Specialty Tier	33%	N/A	P
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER	3	Preferred Brand	$45.00	$112.50	Q:11 /30Days
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL	3	Preferred Brand	$45.00	$112.50	Q:11 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYMLINPEN 120 1000MCG/ML PEN INJECTOR	4	Non-Preferred Brand	$90.00	$225.00	P
SYMLINPEN 60 1000MCG/ML PEN INJECTOR	4	Non-Preferred Brand	$90.00	$225.00	P
SYNALGOS DC CAPSULES 16;356.4;MG;MG;MG;	4	Non-Preferred Brand	$90.00	$225.00	Q:240 /30Days
SYNAREL 2MG/ML NASAL SPRAY	6	Specialty Tier	33%	N/A	P
SYNRIBO 3.5 MG/ML VIAL	6	Specialty Tier	33%	N/A	None
SYNTHROID 100MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 112 MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 125MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
Synthroid 137ug/1 90 TABLET BOTTLE	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 150MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 175MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNTHROID 200MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 25MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 300MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 50MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 75MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYNTHROID 88 MCG TABLET	3	Preferred Brand	$45.00	$112.50	None
SYPRINE 250MG CAPSULE (100 CT)	3	Preferred Brand	$45.00	$112.50	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D Blue Cross MedicareRx Gold (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $325 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2013 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.