2015 Medicare Part D Plan Formulary Information |
Medicare Blue Choice Value (HMO) (H3351-011-0)
Benefit Details
|
The Medicare Blue Choice Value (HMO) (H3351-011-0) Formulary Drugs Starting with the Letter S in LIVINGSTON County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $23.00 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 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SAIZEN 5 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SAIZEN 8.8 MG CLICK.EASY CARTG |
5 |
Specialty Tier |
33% | 33% | P |
SAIZEN 8.8 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Specialty Tier |
33% | 33% | S Q:4 /28Days |
SANDIMMUNE 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SANDIMMUNE 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SANDIMMUNE 50MG/ML AMPUL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SANDOSTATIN 0.05MG/ML AMPUL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDOSTATIN 0.2MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
5 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN 1MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
5 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR 10MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR 20MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR 30MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | 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 | $237.50 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S |
SAVELLA TABLETS 100MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S |
SAVELLA TALBETS 50MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | 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 |
$95.00 | $237.50 | None |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SENSIPAR 60MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
sF Rowasa 4g/60mL |
5 |
Specialty Tier |
33% | 33% | None |
SHAROBEL 0.35 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Signifor .3 mg/mL |
5 |
Specialty Tier |
33% | 33% | None |
Signifor .6 mg/mL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | 33% | None |
SIGNIFOR LAR 20 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
SIGNIFOR LAR 40 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
SIGNIFOR LAR 60 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
Sildenafil 10 mg/12.5 ml vial |
5 |
Specialty Tier |
33% | 33% | P |
SILDENAFIL 20 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | P Q:90 /30Days |
SILENOR 3 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SILENOR 6 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SILVER SULFADIAZINE 1% CRM |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
Simcor ER 1000; 20mg/1; mg 90 FILM COATED TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SIMCOR TABLETS 1000/40MG EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SIMCOR TABLETS 500/40MG EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
SIMPONI 100 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
SIMPONI ARIA 50 MG/4 ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
SIMULECT 20MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | 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 |
$4.00 | $10.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SINEMET 25; 250mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIROLIMUS 2 MG TABLET [Rapamune] |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:68 /28Days |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:6 /6Days |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P Q:6 /6Days |
SKELAXIN 800 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sodium Chloride 3g/100mL |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | 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 |
$8.00 | $20.00 | None |
SODIUM PHENYLBUTYRATE POWDER |
5 |
Specialty Tier |
33% | 33% | None |
sodium polystyrene sulf pwd |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Solodyn 105mg/1 |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
Solodyn 55mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
Solodyn 80mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
SOLODYN ER 115 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
SOLODYN ER 65 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SOLTAMOX 10 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SOLU CORTEF 250MG/VIAL INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SOLU CORTEF INJECTION 100 MG/VIAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLU MEDROL FOR INJECTION 40 MG/ML |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SOLU MEDROL FOR INJECTION 500 MG/ML |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SOLU-MEDROL 2000MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Soma 250mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:120 /30Days |
SOMA 350MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:120 /30Days |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Specialty Tier |
33% | 33% | P |
Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SONATA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
SONATA 5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
SOOLANTRA 1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S |
SORIATANE 10MG CAPSULES |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
SORIATANE 17.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
SORIATANE 25MG CAPSULES |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
SORILUX 50ug/g 60 g in 1 CAN |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | 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 |
$8.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SOTALOL HCL TABLET 240MG |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SOTYLIZE 5 MG/ML ORAL SOLUTION |
5 |
Specialty Tier |
33% | 33% | Q:1920 /30Days |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPECTRACEF 400 MG DOSE PACK TB |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SPINOSAD 0.9% TOPICAL SUSP |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:4 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SPORANOX 100MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | S |
SPORANOX 100MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | S |
SPORANOX 10MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | S |
SPRINTEC 0.25-0.035 TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SPRIX 15.75mg/1 5 BOTTLE, SPRAY per CARTON / 8 SPRAY, METERED in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SRONYX 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
STAVUDINE 1 MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
STERILE WATER FOR IRRIGATION |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
STRATTERA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
STRATTERA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
STRATTERA 18MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
STRATTERA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /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 |
$95.00 | $237.50 | Q:60 /30Days |
STRATTERA 60MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
STRATTERA 80MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
STRIANT 30 MG MUCOADHESIVE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | 33% | None |
STRIVERDI RESPIMAT INHAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:5 /30Days |
STROMECTOL 3MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
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 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUBSYS 1,200 MCG SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
SUBSYS 100 MCG SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
SUBSYS 200 MCG SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
SUBSYS 400 MCG SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
SUBSYS 800 MCG SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
33% | 33% | None |
SUCRALFATE 1GM TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULFAMYLON CREAM 85GM 4 OZ TUBE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SULFASALAZINE 500MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
SULINDAC 200MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 20 MG NASAL SPRAY |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:12 /30Days |
SUMATRIPTAN 5 MG NASAL SPRAY |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:18 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:10 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:18 /30Days |
Sumatriptan Succinate 50 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:18 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:10 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | Q:9 /30Days |
SUMAVEL DOSEPRO 4 MG/0.5 ML |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:5 /30Days |
Sumavel DosePro 6mg/0.5mL 6 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:5 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUPRAX 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUPRAX 500 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | 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 |
$95.00 | $237.50 | None |
SURMONTIL 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SURMONTIL 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Surmontil 50mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUSTIVA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUSTIVA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
SUSTIVA 600MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SYLATRON 296 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 444 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 888 MCG KIT 1 KIT per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SYLVANT 100 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:11 /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 |
$45.00 | $112.50 | Q:11 /30Days |
SYMLINPEN 120 PEN INJECTOR |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMLINPEN 60 PEN INJECTOR |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:12 /28Days |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
SYNERA PATCH |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
SYNERCID 500MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SYNTHROID 100MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 112 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 125MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 150MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 175MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 200MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 25MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 300MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 50MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 75MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYNTHROID 88 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
SYPRINE 250 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |