2014 Medicare Part D Plan Formulary Information |
Fidelis Secure Respect (HMO) (H2323-015-0)
Benefit Details
|
The Fidelis Secure Respect (HMO) (H2323-015-0) Formulary Drugs Starting with the Letter S in MACOMB County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $0.00 Deductible: $0 |
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 per BLISTER PACK |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Saizen 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | P |
SAIZEN CLICKEASY 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | P |
Salagen 5mg/1 |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Salagen 7.5mg/1 |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SANCTURA 20MG TABLETS |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
SANCTURA XR 60MG CAPSULE SR 24 HR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
4 |
Specialty Tier |
33% | 33% | None |
SANDIMMUNE 100MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDIMMUNE 25MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
SANDOSTATIN 0.05MG/ML AMPUL |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SANDOSTATIN 0.2MG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
4 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN 1MG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SANDOSTATIN LAR 10MG KIT |
4 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR 20MG KIT |
4 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR 30MG KIT |
4 |
Specialty Tier |
33% | 33% | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAPHRIS 5 MG TAB SL BLK CHERRY |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:360 /90Days |
SARAFEM 10mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SAVELLA TABLETS 100MG 60 COUNT BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:180 /90Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:1440 /90Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:720 /90Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:1 /90Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:360 /90Days |
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SECTRAL 200MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SECTRAL 400MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELEGILINE HCL 5 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Specialty Tier |
33% | 33% | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Specialty Tier |
33% | 33% | None |
SEMPREX-D 8 MG-60 MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SENSIPAR 30MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SENSIPAR 60MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
SENSIPAR 90MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
SEREVENT DIS AER 50MCG |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /90Days |
SEROMYCIN 250mg/250mg 40 CAPSULE BOTTLE / 250 mg in 1 CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 100MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:720 /90Days |
SEROQUEL 200MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:360 /90Days |
SEROQUEL 25MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:2705 /90Days |
SEROQUEL 300MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:241 /90Days |
SEROQUEL 400MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:180 /90Days |
SEROQUEL 50MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:1440 /90Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:482 /90Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:360 /90Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /90Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:1440 /90Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:241 /90Days |
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 |
4 |
Specialty Tier |
33% | 33% | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
4 |
Specialty Tier |
33% | 33% | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Generic |
$10.00 | $20.00 | Q:180 /90Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:720 /90Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Generic |
$10.00 | $20.00 | Q:360 /90Days |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
1 |
Generic |
$10.00 | $20.00 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
sF Rowasa 4g/60mL |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Signifor .3 mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
Signifor .6 mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .9 mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
SILDENAFIL 20 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | P Q:270 /90Days |
SILENOR 3 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S Q:90 /90Days |
SILENOR 6 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S Q:90 /90Days |
SILVADENE 1% CREAM |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Generic |
$10.00 | $20.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:90 /90Days |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /90Days |
Simcor ER 1000; 20mg/1; mg 90 FILM COATED TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /90Days |
SIMCOR TABLETS 1000/40MG EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMCOR TABLETS 500/40MG EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:90 /90Days |
SIMPONI ARIA 50 MG/4 ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
4 |
Specialty Tier |
33% | 33% | P |
SIMULECT 20MG VIAL |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
SIMVASTATIN 10 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:90 /90Days |
SIMVASTATIN 20 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:90 /90Days |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $20.00 | Q:90 /90Days |
SIMVASTATIN 5 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:90 /90Days |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $20.00 | Q:90 /90Days |
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | 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 |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINGULAIR 10 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINGULAIR 4 MG TABLET CHEW |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINGULAIR 4MG GRANULES |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SINGULAIR 5 MG TABLET CHEW |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
1 |
Generic |
$10.00 | $20.00 | P |
SIRTURO 100 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
SKELAXIN 800MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
SKLICE 0.5% LOTION |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Generic |
$10.00 | $20.00 | None |
Sodium Chloride 3g/100mL |
1 |
Generic |
$10.00 | $20.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
1 |
Generic |
$10.00 | $20.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
1 |
Generic |
$10.00 | $20.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Generic |
$10.00 | $20.00 | None |
SODIUM LACTATE 1/6MOLAR INJ |
1 |
Generic |
$10.00 | $20.00 | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Generic |
$10.00 | $20.00 | None |
SODIUM PHENYLBUTYRATE POWDER |
4 |
Specialty Tier |
33% | 33% | None |
sodium polystyrene sulf pwd |
1 |
Generic |
$10.00 | $20.00 | None |
SOLARAZE 3% GEL |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Solodyn 105mg/1 |
4 |
Specialty Tier |
33% | 33% | None |
Solodyn 55mg/1 |
4 |
Specialty Tier |
33% | 33% | None |
Solodyn 80mg/1 |
4 |
Specialty Tier |
33% | 33% | None |
SOLODYN ER 115 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
SOLODYN ER 65 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
SOLTAMOX 10 MG/5 ML SOLN |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SOLU CORTEF 250MG/VIAL INJECTION |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SOLU CORTEF INJECTION 100 MG/VIAL |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SOLU MEDROL FOR INJECTION 40 MG/ML |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SOLU MEDROL FOR INJECTION 500 MG/ML |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLU-MEDROL 2000MG VIAL |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SOMATULINE 60 MG/0.2 ML SYRING |
4 |
Specialty Tier |
33% | 33% | None |
Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
4 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 10 MG VIAL |
4 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 15 MG VIAL |
4 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 20 MG VIAL |
4 |
Specialty Tier |
33% | 33% | None |
SONATA 10MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S Q:180 /90Days |
SONATA 5MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S Q:90 /90Days |
SORIATANE 10MG CAPSULES |
4 |
Specialty Tier |
33% | 33% | None |
SORIATANE 17.5 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
SORIATANE 25MG CAPSULES |
4 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORILUX 50ug/g 60 g in 1 CAN |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Generic |
$10.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Generic |
$10.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Generic |
$10.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Generic |
$10.00 | $20.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Generic |
$10.00 | $20.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
SOTALOL HYDROCHLORIDE INJECTION 15MG/ML |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SOVALDI 400 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPINOSAD 0.9% TOPICAL SUSP |
1 |
Generic |
$10.00 | $20.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /90Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
SPORANOX 100MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:360 /90Days |
SPORANOX 100MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:360 /90Days |
SPORANOX 10MG/ML SOLUTION |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SPRIX 15.75mg/1 5 BOTTLE, SPRAY per CARTON / 8 SPRAY, METERED in 1 BOTTLE, SPRAY |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
4 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
4 |
Specialty Tier |
33% | 33% | P Q:90 /90Days |
SPRYCEL 20MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 50MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 70MG TABLET |
4 |
Specialty Tier |
33% | 33% | P Q:180 /90Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
4 |
Specialty Tier |
33% | 33% | P |
SRONYX 0.1-0.02 TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
1 |
Generic |
$10.00 | $20.00 | None |
STALEVO 100 TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STALEVO 125/200 MG/MG TABLETS |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STALEVO 150 TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STALEVO 18.75/75 MG/MG TABLETS |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STALEVO 200 50-200-200 TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STALEVO 50 TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STARLIX 120MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:270 /90Days |
STARLIX 60MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:540 /90Days |
STAVUDINE 1 MG/ML SOLUTION |
1 |
Generic |
$10.00 | $20.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
STAVZOR 125MG CPDR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVZOR 250MG CPDR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STAVZOR 500MG CPDR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
STELARA 90 MG/ML SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
4 |
Specialty Tier |
33% | 33% | P |
STERILE WATER FOR IRRIGATION |
1 |
Generic |
$10.00 | $20.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
STIVARGA 40 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P Q:252 /84Days |
STRATTERA 100MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
STRATTERA 10MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
STRATTERA 18MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 25MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
STRATTERA 40MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
STRATTERA 60MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
STRATTERA 80MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
STRIANT 30 MG MUCOADHESIVE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
STRIBILD TABLET |
4 |
Specialty Tier |
33% | 33% | None |
STROMECTOL 3MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUBOXONE 12 MG-3 MG SL FILM |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:270 /90Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:270 /90Days |
SUBOXONE 4 MG-1 MG SL FILM |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:270 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:270 /90Days |
SUBSYS 1,200 MCG SPRAY |
4 |
Specialty Tier |
33% | 33% | P Q:120 /90Days |
SUBSYS 100 MCG SPRAY |
4 |
Specialty Tier |
33% | 33% | P Q:360 /90Days |
SUBSYS 200 MCG SPRAY |
4 |
Specialty Tier |
33% | 33% | P Q:360 /90Days |
SUBSYS 400 MCG SPRAY |
4 |
Specialty Tier |
33% | 33% | P Q:360 /90Days |
SUBSYS 800 MCG SPRAY |
4 |
Specialty Tier |
33% | 33% | P Q:180 /90Days |
SUCLEAR BOWEL PREP KIT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUCRAID 8500[iU]/mL |
4 |
Specialty Tier |
33% | 33% | None |
SUCRALFATE 1GM TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SULAR 17MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
SULAR 34MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULAR 8.5MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
SULFACETAMIDE 10% EYE OINTMENT |
1 |
Generic |
$10.00 | $20.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Generic |
$10.00 | $20.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Generic |
$10.00 | $20.00 | None |
SULFADIAZINE 500MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
1 |
Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
SULFAMYLON 50G PACKET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Generic |
$10.00 | $20.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
SULINDAC 200MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY |
1 |
Generic |
$10.00 | $20.00 | Q:54 /84Days |
SUMATRIPTAN 5 MG NASAL SPRAY |
1 |
Generic |
$10.00 | $20.00 | Q:108 /84Days |
Sumatriptan 6 mg/0.5 ml vial |
1 |
Generic |
$10.00 | $20.00 | Q:48 /84Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
1 |
Generic |
$10.00 | $20.00 | Q:54 /84Days |
Sumatriptan Succinate 50 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:54 /84Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
1 |
Generic |
$10.00 | $20.00 | Q:48 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Generic |
$10.00 | $20.00 | Q:54 /84Days |
Sumavel DosePro 6mg/0.5mL 6 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:48 /84Days |
SUPRAX 100 MG TABLET CHEWABLE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUPRAX 400 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUPRAX 400 MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUPRAX 500 MG/5 ML SUSPENSION |
2 |
Preferred Brand |
$45.00 | $90.00 | 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 |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SURMONTIL 100MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SURMONTIL 25MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
Surmontil 50mg/1 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
SUSTIVA 200MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUSTIVA 50MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUSTIVA 600MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
SUTENT 12.5MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
4 |
Specialty Tier |
33% | 33% | P Q:180 /90Days |
SUTENT 50MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P Q:90 /90Days |
SYLATRON 296 MCG KIT 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | None |
SYLATRON 444 MCG KIT 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | None |
SYLATRON 888 MCG KIT 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | None |
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 |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:31 /90Days |
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:21 /90Days |
SYMBYAX 12-25MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYMBYAX 12-50MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYMBYAX 6-25MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYMBYAX 6-50MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYMLINPEN 120 1000MCG/ML PEN INJECTOR |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:57 /90Days |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
2 |
Preferred Brand |
$45.00 | $90.00 | P Q:32 /90Days |
SYNAGIS 50MG/0.5ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
SYNALAR 0.025% CREAM KIT |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNALGOS DC CAPSULES 16;356.4;MG;MG;MG; |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:900 /90Days |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Specialty Tier |
33% | 33% | None |
SYNERA PATCH |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNERCID 500MG VIAL |
4 |
Specialty Tier |
33% | 33% | None |
SYNRIBO 3.5 MG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
SYNTHROID 100MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 112 MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 125MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 150MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 175MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 200MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 25MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 300MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 50MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 75MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYNTHROID 88 MCG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SYPRINE 250MG CAPSULE (100 CT) |
4 |
Specialty Tier |
33% | 33% | None |