2014 Medicare Part D Plan Formulary Information |
First Health Part D Premier Plus (PDP) (S5670-096-0)
Benefit Details
|
The First Health Part D Premier Plus (PDP) (S5670-096-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 18 which includes: MO Plan Monthly Premium: $106.60 Deductible: $0 Qualifies for LIS: No |
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 |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
4 |
Non-Preferred Brand |
41% | 41% | Q:4 /28Days |
SANDIMMUNE 100MG CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | P |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Brand |
41% | 41% | P |
SANDIMMUNE 25MG CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | P |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Brand |
41% | 41% | Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Brand |
41% | 41% | Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEMPREX-D 8 MG-60 MG CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | None |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
SENSIPAR 60MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
SENSIPAR 90MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:120 /30Days |
SEREVENT DIS AER 50MCG |
4 |
Non-Preferred Brand |
41% | 41% | Q:60 /30Days |
SEROMYCIN 250mg/250mg 40 CAPSULE BOTTLE / 250 mg in 1 CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | None |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Preferred Brand |
25% | 25% | 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 per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
25% | 25% | Q:90 /30Days |
SILDENAFIL 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
SILVER SULFADIAZINE 1% CRM |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
4 |
Non-Preferred Brand |
41% | 41% | None |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | P |
SINGULAIR 4MG GRANULES |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
4 |
Non-Preferred Brand |
41% | 41% | P |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SODIUM PHENYLBUTYRATE POWDER |
5 |
Specialty Tier |
33% | N/A | P |
sodium polystyrene sulf pwd |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLTAMOX 10 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
41% | 41% | P |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SORIATANE 10MG CAPSULES |
4 |
Non-Preferred Brand |
41% | 41% | P |
SORIATANE 17.5 MG CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | P |
SORIATANE 25MG CAPSULES |
4 |
Non-Preferred Brand |
41% | 41% | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | 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 |
$25.00 | $62.50 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SOTALOL HCL TABLET 240MG |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPORANOX 10MG/ML SOLUTION |
4 |
Non-Preferred Brand |
41% | 41% | P |
SPRINTEC 0.25-0.035 TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per 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:60 /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 per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SRONYX 0.1-0.02 TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
STAVUDINE 1 MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
4 |
Non-Preferred Brand |
41% | 41% | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
STROMECTOL 3MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Brand |
41% | 41% | P Q:90 /30Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
41% | 41% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Brand |
41% | 41% | P Q:90 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
41% | 41% | P Q:90 /30Days |
SUCLEAR BOWEL PREP KIT |
4 |
Non-Preferred Brand |
41% | 41% | Q:1 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
33% | N/A | P |
SUCRALFATE 1GM TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SULFACETAMIDE 10% EYE OINTMENT |
4 |
Non-Preferred Brand |
41% | 41% | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULFADIAZINE 500MG TABLET |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | 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 |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULFAMETHOXAZOLE-TMP DS TABLET |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULFAMYLON 50G PACKET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
4 |
Non-Preferred Brand |
41% | 41% | None |
SULFASALAZINE 500MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
SULINDAC 150MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SULINDAC 200MG TABLET |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
SUMATRIPTAN 20 MG NASAL SPRAY |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:8 /30Days |
SUMATRIPTAN 5 MG NASAL SPRAY |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:8 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Non-Preferred Brand |
41% | 41% | Q:8 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:9 /30Days |
Sumatriptan Succinate 50 MG TABLET |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:9 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
4 |
Non-Preferred Brand |
41% | 41% | Q:8 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:9 /30Days |
Sumavel DosePro 6mg/0.5mL 6 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
4 |
Non-Preferred Brand |
41% | 41% | S Q:8 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
3 |
Preferred Brand |
25% | 25% | None |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
3 |
Preferred Brand |
25% | 25% | None |
SUPRAX 200 MG TABLET CHEWABLE |
3 |
Preferred Brand |
25% | 25% | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Preferred Brand |
25% | 25% | None |
SUPRAX 400 MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 400 MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
SUPRAX 500 MG/5 ML SUSPENSION |
3 |
Preferred Brand |
25% | 25% | None |
SUPREP bowel prep 1.6; 3.13; 17.5g/mL; g/mL; g/mL 2 BOTTLE, PLASTIC per CARTON / 177.4 mL in 1 BOT |
4 |
Non-Preferred Brand |
41% | 41% | Q:1 /30Days |
SUSTIVA 200MG CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | None |
SUSTIVA 50MG CAPSULE |
4 |
Non-Preferred Brand |
41% | 41% | None |
SUSTIVA 600MG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SYLATRON 296 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
SYLATRON 444 MCG KIT 1 KIT per 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 |
25% | 25% | Q:10 /30Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
3 |
Preferred Brand |
25% | 25% | Q:10 /30Days |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
41% | 41% | P Q:4 /30Days |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
41% | 41% | P Q:8 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | P |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SYNTHROID 100MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 112 MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 125MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 150MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 175MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 200MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 25MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 300MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 50MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 75MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYNTHROID 88 MCG TABLET |
4 |
Non-Preferred Brand |
41% | 41% | None |
SYPRINE 250MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
41% | 41% | None |