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2013 Medicare Part D Plan Formulary Information
EnvisionRxPlus Gold (PDP) (S7694-095-0) Benefit Details
The EnvisionRxPlus Gold (PDP) (S7694-095-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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
Saizen 1 KIT in 1 CARTON	5	Specialty Tier	29%	N/A	P
SAIZEN CLICKEASY 1 KIT in 1 CARTON	5	Specialty Tier	29%	N/A	P
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN	3	Preferred Brand	1%	1%	Q:4 /30Days
SANDIMMUNE 100MG CAPSULE	4	Non-Preferred Brand	30%	30%	P
SANDIMMUNE 100MG/ML TUBEX	4	Non-Preferred Brand	30%	30%	P
SANDIMMUNE 25MG CAPSULE	4	Non-Preferred Brand	30%	30%	P
SANDIMMUNE 50MG/ML AMPUL	4	Non-Preferred Brand	30%	30%	P
SANDOSTATIN LAR 10MG KIT	5	Specialty Tier	29%	N/A	None
SANDOSTATIN LAR 20MG KIT	5	Specialty Tier	29%	N/A	None
SANDOSTATIN LAR 30MG KIT	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK	4	Non-Preferred Brand	30%	30%	None
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK	4	Non-Preferred Brand	30%	30%	None
SAVELLA TABLETS 100MG 60 COUNT BOT	3	Preferred Brand	1%	1%	None
SAVELLA TABLETS 12.5MG 60 COUNT BOT	3	Preferred Brand	1%	1%	None
SAVELLA TABLETS 25MG 60 COUNT BOT	3	Preferred Brand	1%	1%	None
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM	3	Preferred Brand	1%	1%	None
SAVELLA TALBETS 50MG 60 COUNT BOT	3	Preferred Brand	1%	1%	None
SELEGILINE HCL 5 MG TABLET	2	Non-Preferred Generic	1%	1%	None
SELEGILINE HCL 5MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE	1	Preferred Generic	1%	1%	None
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE	5	Specialty Tier	29%	N/A	None
SENSIPAR 30MG TABLET	3	Preferred Brand	1%	1%	None
SENSIPAR 60MG TABLET	5	Specialty Tier	29%	N/A	None
SENSIPAR 90MG TABLET	5	Specialty Tier	29%	N/A	None
SEREVENT DIS AER 50MCG	3	Preferred Brand	1%	1%	None
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE	4	Non-Preferred Brand	30%	30%	None
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN	3	Preferred Brand	1%	1%	None
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN	3	Preferred Brand	1%	1%	None
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN	3	Preferred Brand	1%	1%	None
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN	3	Preferred Brand	1%	1%	None
SEROQUEL XR 300MG TABLET 60X300MG BOT	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SERTRALINE HCL 100MG TABLET (30 CT)	2	Non-Preferred Generic	1%	1%	None
SERTRALINE HCL 25 MG TABLET	2	Non-Preferred Generic	1%	1%	None
SERTRALINE HCL 50MG TABLET (30 CT)	2	Non-Preferred Generic	1%	1%	None
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE	2	Non-Preferred Generic	1%	1%	None
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]	4	Non-Preferred Brand	30%	30%	None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]	4	Non-Preferred Brand	30%	30%	None
SILDENAFIL 20 MG TABLET	2	Non-Preferred Generic	1%	1%	P
SILVER SULFADIAZINE 1% CRM	1	Preferred Generic	1%	1%	None
SIMVASTATIN 10 MG TABLET	2	Non-Preferred Generic	1%	1%	None
SIMVASTATIN 20 MG TABLET	2	Non-Preferred Generic	1%	1%	None
SIMVASTATIN 40MG TABLET (500 CT)	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SIMVASTATIN 5 MG TABLET	2	Non-Preferred Generic	1%	1%	None
SIMVASTATIN 80MG TABLET (1000 CT)	2	Non-Preferred Generic	1%	1%	None
SIRTURO 100 MG TABLET	5	Specialty Tier	29%	N/A	None
SODIUM CHLORIDE 0.45% TUBEX	2	Non-Preferred Generic	1%	1%	None
Sodium Chloride 3g/100mL	1	Preferred Generic	1%	1%	None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	1%	1%	None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG	2	Non-Preferred Generic	1%	1%	None
SODIUM CHLORIDE INJECTION USP 5%	1	Preferred Generic	1%	1%	None
SODIUM CL 2.5 MEQ/ML VIAL	1	Preferred Generic	1%	1%	None
SODIUM LACTATE 1/6MOLAR INJ	1	Preferred Generic	1%	1%	None
SODIUM LACTATE 5 MEQ/ML VIAL	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SODIUM PHENYLBUTYRATE POWDER	2	Non-Preferred Generic	1%	1%	None
sodium polystyrene sulf pwd	2	Non-Preferred Generic	1%	1%	None
SOLARAZE 3% GEL	3	Preferred Brand	1%	1%	Q:200 /30Days
SOLTAMOX 10 MG/5 ML SOLN	4	Non-Preferred Brand	30%	30%	None
SOMATULINE 60 MG/0.2 ML SYRING	5	Specialty Tier	29%	N/A	None
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE	5	Specialty Tier	29%	N/A	None
SOMAVERT 10MG VIAL	5	Specialty Tier	29%	N/A	None
SOMAVERT 15MG VIAL	5	Specialty Tier	29%	N/A	None
SOMAVERT 20MG VIAL	5	Specialty Tier	29%	N/A	None
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD	2	Non-Preferred Generic	1%	1%	None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD	2	Non-Preferred Generic	1%	1%	None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD	1	Preferred Generic	1%	1%	None
SOTALOL HCL TABLET 240MG	2	Non-Preferred Generic	1%	1%	None
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	1%	1%	None
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	None
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK	3	Preferred Brand	1%	1%	None
SPIRONOLACTONE 100MG TABLET	2	Non-Preferred Generic	1%	1%	None
SPIRONOLACTONE 25MG TABLET (100 CT)	1	Preferred Generic	1%	1%	None
SPIRONOLACTONE 50MG TABLET (100 CT)	2	Non-Preferred Generic	1%	1%	None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)	2	Non-Preferred Generic	1%	1%	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	29%	N/A	None
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE	5	Specialty Tier	29%	N/A	None
SPRYCEL 20MG TABLET	5	Specialty Tier	29%	N/A	None
SPRYCEL 50MG TABLET	5	Specialty Tier	29%	N/A	None
SPRYCEL 70MG TABLET	5	Specialty Tier	29%	N/A	None
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET BOTTLE	5	Specialty Tier	29%	N/A	None
SSD Cream 10g/1000g 85 g in 1 TUBE	1	Preferred Generic	1%	1%	None
STALEVO 100 TABLET	3	Preferred Brand	1%	1%	None
STALEVO 125/200 MG/MG TABLETS	3	Preferred Brand	1%	1%	None
STALEVO 150 TABLET	3	Preferred Brand	1%	1%	None
STALEVO 18.75/75 MG/MG TABLETS	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STALEVO 200 50-200-200 TABLET	3	Preferred Brand	1%	1%	None
STALEVO 50 TABLET	3	Preferred Brand	1%	1%	None
STAVUDINE 1 MG/ML SOLUTION	2	Non-Preferred Generic	1%	1%	None
STAVUDINE CAPSULES 15MG 60 BOT	2	Non-Preferred Generic	1%	1%	None
STAVUDINE CAPSULES 20MG 60 BOT	2	Non-Preferred Generic	1%	1%	None
STAVUDINE CAPSULES 30MG 60 BOT	2	Non-Preferred Generic	1%	1%	None
STAVUDINE CAPSULES 40MG 60 BOT	2	Non-Preferred Generic	1%	1%	None
STIVARGA 40 MG TABLET	5	Specialty Tier	29%	N/A	P
STRATTERA 100MG CAPSULE	3	Preferred Brand	1%	1%	None
STRATTERA 10MG CAPSULE	3	Preferred Brand	1%	1%	None
STRATTERA 18MG CAPSULE	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STRATTERA 25MG CAPSULE	3	Preferred Brand	1%	1%	None
STRATTERA 40MG CAPSULE	3	Preferred Brand	1%	1%	None
STRATTERA 60MG CAPSULE	3	Preferred Brand	1%	1%	None
STRATTERA 80MG CAPSULE	3	Preferred Brand	1%	1%	None
STREPTOMYCIN FOR INJECTION 1GM/VIL	2	Non-Preferred Generic	1%	1%	None
STRIBILD TABLET	5	Specialty Tier	29%	N/A	None
STROMECTOL 3MG TABLET	3	Preferred Brand	1%	1%	None
SUBOXONE 12 MG-3 MG SL FILM	4	Non-Preferred Brand	30%	30%	None
SUBOXONE 4 MG-1 MG SL FILM	4	Non-Preferred Brand	30%	30%	None
SUCRALFATE 1GM TABLET	2	Non-Preferred Generic	1%	1%	None
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT	1	Preferred Generic	1%	1%	None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS	1	Preferred Generic	1%	1%	None
SULFADIAZINE 500MG TABLET	2	Non-Preferred Generic	1%	1%	None
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE	1	Preferred Generic	1%	1%	None
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)	1	Preferred Generic	1%	1%	None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL	2	Non-Preferred Generic	1%	1%	None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)	1	Preferred Generic	1%	1%	None
SULFASALAZINE 500MG TABLET	2	Non-Preferred Generic	1%	1%	None
SULFAZINE EC 500MG TABLET DELAYED RELEASE	2	Non-Preferred Generic	1%	1%	None
SULINDAC 150MG TABLET (100 CT)	2	Non-Preferred Generic	1%	1%	None
SULINDAC 200MG TABLET	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Sumatriptan 6 mg/0.5 ml vial	2	Non-Preferred Generic	1%	1%	Q:4 /30Days
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE	2	Non-Preferred Generic	1%	1%	Q:5 /30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD	2	Non-Preferred Generic	1%	1%	Q:9 /30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX	2	Non-Preferred Generic	1%	1%	Q:9 /30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX	2	Non-Preferred Generic	1%	1%	Q:9 /30Days
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL	4	Non-Preferred Brand	30%	30%	None
SUPRAX 400 MG TABLET	4	Non-Preferred Brand	30%	30%	None
SUSTIVA 200MG CAPSULE	3	Preferred Brand	1%	1%	None
SUSTIVA 50MG CAPSULE	3	Preferred Brand	1%	1%	None
SUSTIVA 600MG TABLET	3	Preferred Brand	1%	1%	None
SUTENT 12.5MG CAPSULE	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE	5	Specialty Tier	29%	N/A	None
SUTENT 50MG CAPSULE	5	Specialty Tier	29%	N/A	None
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON	5	Specialty Tier	29%	N/A	None
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON	5	Specialty Tier	29%	N/A	None
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON	5	Specialty Tier	29%	N/A	None
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER	3	Preferred Brand	1%	1%	None
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL	3	Preferred Brand	1%	1%	None
SYMLINPEN 120 1000MCG/ML PEN INJECTOR	4	Non-Preferred Brand	30%	30%	None
SYMLINPEN 60 1000MCG/ML PEN INJECTOR	4	Non-Preferred Brand	30%	30%	None
SYNAREL 2MG/ML NASAL SPRAY	5	Specialty Tier	29%	N/A	None
SYNRIBO 3.5 MG/ML VIAL	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNTHROID 100MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 112 MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 125MCG TABLET	4	Non-Preferred Brand	30%	30%	None
Synthroid 137ug/1 90 TABLET BOTTLE	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 150MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 175MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 200MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 25MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 300MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 50MCG TABLET	4	Non-Preferred Brand	30%	30%	None
SYNTHROID 75MCG TABLET	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNTHROID 88 MCG TABLET	4	Non-Preferred Brand	30%	30%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D EnvisionRxPlus 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.