2015 Medicare Part D Plan Formulary Information |
United American - Select (PDP) (S5755-102-0)
Sanctioned Plan
 |
The United American - Select (PDP) (S5755-102-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $41.50 Deductible: $320 Qualifies for LIS: Yes |
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 |
SANDIMMUNE 100MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | P |
SANDIMMUNE 100MG/ML TUBEX  |
3 |
Preferred Brand |
14% | 19% | P |
SANDIMMUNE 25MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | 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 |
SAPHRIS 10 MG TAB SL BLK CHERY  |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY  |
4 |
Non-Preferred Brand |
24% | N/A | Q:240 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY  |
4 |
Non-Preferred Brand |
24% | N/A | Q:120 /30Days |
SELEGILINE HCL 5 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELEGILINE HCL 5MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE  |
5 |
Specialty Tier |
25% | N/A | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE  |
5 |
Specialty Tier |
25% | N/A | None |
SENSIPAR 30MG TABLET  |
3 |
Preferred Brand |
14% | 19% | Q:120 /30Days |
SENSIPAR 60MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SENSIPAR 90MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
SEREVENT DIS AER 50MCG  |
3 |
Preferred Brand |
14% | 19% | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN  |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN  |
4 |
Non-Preferred Brand |
24% | N/A | Q:120 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT  |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
SERTRALINE HCL 100MG TABLET (30 CT)  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SERTRALINE HCL 25 MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
SERTRALINE HCL 50MG TABLET (30 CT)  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE  |
3 |
Preferred Brand |
14% | 19% | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] ![Compare how all Medicare Part D PDP plans in ID cover SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] ![Compare how all Medicare Part D PDP plans in ID cover SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
SHAROBEL 0.35 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
SILDENAFIL 20 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
SILENOR 3 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILENOR 6 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
SILVER SULFADIAZINE 1% CRM  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS  |
3 |
Preferred Brand |
14% | 19% | None |
SIMVASTATIN 10 MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 40MG TABLET (500 CT)  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 80MG TABLET (1000 CT)  |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] ![Compare how all Medicare Part D PDP plans in ID cover Sirolimus 0.5 MG Tablet [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
24% | N/A | P |
SIROLIMUS 1 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in ID cover SIROLIMUS 1 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
24% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in ID cover SIROLIMUS 2 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIRTURO 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
SIVEXTRO 200 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
SIVEXTRO 200 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SODIUM CHLORIDE 0.45% TUBEX  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Sodium Chloride 3g/100mL  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SODIUM CHLORIDE INJECTION USP 5%  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SODIUM PHENYLBUTYRATE POWDER  |
5 |
Specialty Tier |
25% | N/A | None |
sodium polystyrene sulf pwd  |
3 |
Preferred Brand |
14% | 19% | 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 |
24% | N/A | None |
SOLU CORTEF 250MG/VIAL INJECTION  |
3 |
Preferred Brand |
14% | 19% | 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 |
SOMAVERT 15 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 20 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 25 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 30 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | 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 |
$3.00 | $33.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SOTALOL HCL TABLET 240MG  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC  |
3 |
Preferred Brand |
14% | 19% | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SOVALDI 400 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY  |
3 |
Preferred Brand |
14% | 19% | Q:4 /30Days |
SPIRONOLACTONE 100MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 50MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SPRINTEC 0.25-0.035 TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
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  |
3 |
Preferred Brand |
14% | 19% | None |
SSD Cream 10g/1000g 85 g in 1 TUBE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE 1 MG/ML SOLUTION  |
4 |
Non-Preferred Brand |
24% | N/A | None |
STAVUDINE CAPSULES 15MG 60 BOT  |
3 |
Preferred Brand |
14% | 19% | None |
STAVUDINE CAPSULES 20MG 60 BOT  |
3 |
Preferred Brand |
14% | 19% | None |
STAVUDINE CAPSULES 30MG 60 BOT  |
3 |
Preferred Brand |
14% | 19% | None |
STAVUDINE CAPSULES 40MG 60 BOT  |
3 |
Preferred Brand |
14% | 19% | None |
STERILE WATER FOR IRRIGATION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
STIVARGA 40 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
STRATTERA 100MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
STRATTERA 10MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:120 /30Days |
STRATTERA 18MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:120 /30Days |
STRATTERA 25MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 40MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
STRATTERA 60MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
STRATTERA 80MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL  |
4 |
Non-Preferred Brand |
24% | N/A | None |
STRIBILD TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
SUBOXONE 12 MG-3 MG SL FILM  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:60 /30Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:120 /30Days |
SUBOXONE 4 MG-1 MG SL FILM  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:120 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:120 /30Days |
SUCRAID 8500[iU]/mL ![Compare how all Medicare Part D PDP plans in ID cover SUCRAID 8500[iU]/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
SUCRALFATE 1GM TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE 10% EYE OINTMENT  |
3 |
Preferred Brand |
14% | 19% | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT  |
3 |
Preferred Brand |
14% | 19% | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL  |
3 |
Preferred Brand |
14% | 19% | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SULFASALAZINE 500MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAZINE EC 500MG TABLET DELAYED RELEASE  |
3 |
Preferred Brand |
14% | 19% | None |
SULINDAC 150MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SULINDAC 200MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY  |
4 |
Non-Preferred Brand |
24% | N/A | Q:12 /30Days |
SUMATRIPTAN 5 MG NASAL SPRAY  |
4 |
Non-Preferred Brand |
24% | N/A | Q:24 /30Days |
Sumatriptan 6 mg/0.5 ml vial  |
4 |
Non-Preferred Brand |
24% | N/A | Q:6 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK  |
3 |
Preferred Brand |
14% | 19% | Q:9 /30Days |
Sumatriptan Succinate 50 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | Q:9 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE  |
4 |
Non-Preferred Brand |
24% | N/A | Q:6 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD  |
3 |
Preferred Brand |
14% | 19% | Q:9 /30Days |
SUPRAX 100 MG TABLET CHEWABLE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT  |
3 |
Preferred Brand |
14% | 19% | None |
SUPRAX 200 MG TABLET CHEWABLE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL  |
3 |
Preferred Brand |
14% | 19% | None |
SUPRAX 400 MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
SUPRAX 500 MG/5 ML SUSPENSION  |
3 |
Preferred Brand |
14% | 19% | 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 |
24% | N/A | None |
SURMONTIL 100MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:60 /30Days |
SURMONTIL 25MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:240 /30Days |
Surmontil 50mg/1 100 CAPSULE BOTTLE  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:120 /30Days |
SUSTIVA 200MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
SUSTIVA 50MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 600MG TABLET  |
5 |
Specialty Tier |
25% | N/A | 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 37.5 MG CAPSULE  |
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 |
14% | 19% | Q:10 /30Days |
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER  |
3 |
Preferred Brand |
14% | 19% | Q:10 /30Days |
SYMLINPEN 120 PEN INJECTOR  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:11 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMLINPEN 60 PEN INJECTOR  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:12 /30Days |
SYNAGIS 50MG/0.5ML VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SYNAREL 2MG/ML NASAL SPRAY  |
5 |
Specialty Tier |
25% | N/A | None |
SYNERCID 500MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SYNTHROID 100MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 112 MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 125MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Synthroid 137ug/1 90 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 150MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 175MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 200MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 25MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 300MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 50MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 75MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYNTHROID 88 MCG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
SYPRINE 250 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | None |