2014 Medicare Part D Plan Formulary Information |
Community Care - Plus (HMO-POS) (H2911-001-0)
Benefit Details
|
The Community Care - Plus (HMO-POS) (H2911-001-0) Formulary Drugs Starting with the Letter S in DE SOTO Parish, LA: CMS MA Region 16 which includes: LA Plan Monthly Premium: $0.00 Deductible: $200 |
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 |
Saizen 1 KIT per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
SAIZEN CLICKEASY 1 KIT per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:4 /30Days |
SANDIMMUNE 100MG CAPSULE |
3* |
Preferred Brand |
$45.00 | $135.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
3* |
Preferred Brand |
$45.00 | $135.00 | P |
SANDIMMUNE 25MG CAPSULE |
3* |
Preferred Brand |
$45.00 | $135.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
SANDOSTATIN LAR 10MG KIT |
5 |
Specialty Tier |
25% | N/A | P |
SANDOSTATIN LAR 20MG KIT |
5 |
Specialty Tier |
25% | N/A | P |
SANDOSTATIN LAR 30MG KIT |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:60 /30Days |
SARAFEM 10mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days |
SELEGILINE HCL 5 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
SEMPREX-D 8 MG-60 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SENSIPAR 30MG 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 60MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
SEREVENT DIS AER 50MCG |
3* |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
SEROMYCIN 250mg/250mg 40 CAPSULE BOTTLE / 250 mg in 1 CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3* |
Preferred Brand |
$45.00 | $135.00 | S Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3* |
Preferred Brand |
$45.00 | $135.00 | S Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3* |
Preferred Brand |
$45.00 | $135.00 | S Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3* |
Preferred Brand |
$45.00 | $135.00 | S Q:30 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3* |
Preferred Brand |
$45.00 | $135.00 | S Q:60 /30Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
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 |
$10.00 | $30.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:45 /30Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:45 /30Days |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | 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 |
Signifor .3 mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Signifor .6 mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Signifor .9 mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SILDENAFIL 20 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILVER SULFADIAZINE 1% CRM |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Simcor ER 1000; 20mg/1; mg 90 FILM COATED TABLET BOTTLE |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SIMCOR TABLETS 1000/40MG EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SIMCOR TABLETS 500/40MG EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SIMULECT 20MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
SIMVASTATIN 10 MG TABLET |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SIMVASTATIN 20 MG TABLET |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SIMVASTATIN 5 MG TABLET |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 80MG TABLET (1000 CT) |
1* |
Preferred Generic |
$3.00 | $9.00 | P |
Sirolimus 0.5 MG Tablet [Rapamune] |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | P |
SIRTURO 100 MG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SKLICE 0.5% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SODIUM CHLORIDE 0.45% TUBEX |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
Sodium Chloride 3g/100mL |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SODIUM LACTATE 1/6MOLAR INJ |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM LACTATE 5 MEQ/ML VIAL |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SODIUM PHENYLBUTYRATE POWDER |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
sodium polystyrene sulf pwd |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | 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 CORTEF 250MG/VIAL INJECTION |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SOLU MEDROL FOR INJECTION 500 MG/ML |
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 |
25% | N/A | P |
Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
SORIATANE 10MG CAPSULES |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SORIATANE 17.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SORIATANE 25MG CAPSULES |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SOTALOL HCL TABLET 240MG |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SOTALOL HYDROCHLORIDE INJECTION 15MG/ML |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
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 |
$3.00 | $9.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SPORANOX 10MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
SPRINTEC 0.25-0.035 TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
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 |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P |
SRONYX 0.1-0.02 TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
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 |
STALEVO 150 TABLET |
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 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 |
STAVUDINE 1 MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVZOR 125MG CPDR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVZOR 250MG CPDR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STAVZOR 500MG CPDR |
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 |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
STERILE WATER FOR IRRIGATION |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
STRATTERA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
STRATTERA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
STRATTERA 18MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
STRATTERA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
STRATTERA 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 60MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
STRATTERA 80MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
STROMECTOL 3MG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SUCRALFATE 1GM TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFADIAZINE 500MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
SULFAMYLON 50G PACKET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SULFASALAZINE 500MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULINDAC 150MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SULINDAC 200MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 5 MG NASAL SPRAY |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:18 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:18 /30Days |
Sumatriptan Succinate 50 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:18 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:8 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | Q:18 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUPRAX 400 MG 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 |
SUPRAX 500 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUSTIVA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUSTIVA 50MG CAPSULE |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SUSTIVA 600MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
25% | N/A | P |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
SYLATRON 296 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
SYLATRON 444 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
SYLATRON 888 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3* |
Preferred Brand |
$45.00 | $135.00 | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 | P |
SYMLINPEN 60 1000MCG/ML PEN INJECTOR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
SYNALGOS DC CAPSULES 16;356.4;MG;MG;MG; |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
25% | N/A | None |
SYNERA PATCH |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
SYNERCID 500MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
SYNTHROID 100MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 112 MCG TABLET |
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 |
SYNTHROID 125MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 150MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 175MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 200MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 25MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 300MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 50MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 75MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYNTHROID 88 MCG TABLET |
3* |
Preferred Brand |
$45.00 | $135.00 | None |
SYPRINE 250MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |