2016 Medicare Part D Plan Formulary Information |
Medica Prime Solution Enhanced w/Rx 2 (Cost) (H2450-002-0)
Benefit Details
|
The Medica Prime Solution Enhanced w/Rx 2 (Cost) (H2450-002-0) Formulary Drugs Starting with the Letter S in Eau Claire County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $229.00 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 |
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 |
SANDOSTATIN LAR DEPOT 10 MG KT |
5 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR DEPOT 20 MG KT |
5 |
Specialty Tier |
33% | 33% | None |
SANDOSTATIN LAR DEPOT 30 MG KT |
5 |
Specialty Tier |
33% | 33% | None |
SANTYL OINTMENT |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVAYSA 15 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SAVAYSA 30 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SAVAYSA 60 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Generic |
$20.00 | $40.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | 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 |
$35.00 | $70.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S 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% | 33% | P |
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 |
$10.00 | $20.00 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
2 |
Generic |
$20.00 | $40.00 | None |
SETLAKIN 0.15 MG-0.03 MG TAB |
2 |
Generic |
$20.00 | $40.00 | Q:91 /84Days |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SHAROBEL 0.35 MG TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
Signifor .3 mg/mL |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .6 mg/mL |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
Sildenafil 10 mg/12.5 ml vial |
5 |
Specialty Tier |
33% | 33% | P Q:38 /1Days |
SILDENAFIL 20 MG TABLET |
2 |
Generic |
$20.00 | $40.00 | P Q:90 /30Days |
SILENOR 3 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
SILENOR 6 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
SILVER SULFADIAZINE 1% CRM |
2 |
Generic |
$20.00 | $40.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | P |
SIMPONI 100 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Generic |
$20.00 | $40.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Generic |
$20.00 | $40.00 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
5 |
Specialty Tier |
33% | 33% | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:188 /168Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Generic |
$20.00 | $40.00 | None |
Sodium Chloride 3g/100mL |
2 |
Generic |
$20.00 | $40.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $40.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
2 |
Generic |
$20.00 | $40.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Generic |
$20.00 | $40.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
2 |
Generic |
$20.00 | $40.00 | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
2 |
Generic |
$20.00 | $40.00 | None |
sodium polystyrene sulf pwd |
2 |
Generic |
$20.00 | $40.00 | None |
SOLTAMOX 10 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SOLU CORTEF 250MG/VIAL INJECTION |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SOLU CORTEF INJECTION 100 MG/VIAL |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days |
SOMATULINE DEPOT 120 MG/0.5 ML |
5 |
Specialty Tier |
33% | 33% | 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% | 33% | Q:1 /28Days |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Generic |
$20.00 | $40.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Generic |
$20.00 | $40.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2 |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Generic |
$20.00 | $40.00 | None |
SOTALOL HCL TABLET 240MG |
2 |
Generic |
$20.00 | $40.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $40.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
2 |
Generic |
$20.00 | $40.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $40.00 | None |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:28 /28Days |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SPIRONOLACTONE 100MG TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
2 |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 50MG TABLET (100 CT) |
2 |
Generic |
$20.00 | $40.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
2 |
Generic |
$20.00 | $40.00 | None |
SPORANOX 10MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:60 /30Days |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:120 /30Days |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:120 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /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 |
Generic |
$20.00 | $40.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
2 |
Generic |
$20.00 | $40.00 | None |
STAVUDINE 1 MG/ML SOLUTION |
2 |
Generic |
$20.00 | $40.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Generic |
$20.00 | $40.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Generic |
$20.00 | $40.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Generic |
$20.00 | $40.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Generic |
$20.00 | $40.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
Generic |
$20.00 | $40.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /28Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:84 /28Days |
STRATTERA 100MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
STRATTERA 10MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
STRATTERA 18MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
STRATTERA 25MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
STRATTERA 40MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 60MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
STRATTERA 80MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
STRENSIQ 40 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
STRENSIQ 80 MG/0.8 ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2 |
Generic |
$20.00 | $40.00 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | 33% | None |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
SUCRALFATE 1GM TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Generic |
$20.00 | $40.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | $40.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Generic |
$20.00 | $40.00 | 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 |
Generic |
$20.00 | $40.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
2 |
Generic |
$20.00 | $40.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL |
2 |
Generic |
$20.00 | $40.00 | None |
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
2 |
Generic |
$20.00 | $40.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
SULFASALAZINE 500MG TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2 |
Generic |
$20.00 | $40.00 | None |
SULINDAC 150MG TABLET (100 CT) |
2 |
Generic |
$20.00 | $40.00 | None |
SULINDAC 200MG TABLET |
2 |
Generic |
$20.00 | $40.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY |
2 |
Generic |
$20.00 | $40.00 | Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 4 MG/0.5 ML CART |
2 |
Generic |
$20.00 | $40.00 | Q:4 /28Days |
SUMATRIPTAN 5 MG NASAL SPRAY |
2 |
Generic |
$20.00 | $40.00 | Q:12 /28Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$20.00 | $40.00 | Q:4 /28Days |
SUMATRIPTAN 6 MG/0.5 ML REFILL |
2 |
Generic |
$20.00 | $40.00 | Q:4 /28Days |
Sumatriptan 6 mg/0.5 ml vial |
2 |
Generic |
$20.00 | $40.00 | Q:4 /28Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2 |
Generic |
$20.00 | $40.00 | Q:18 /28Days |
Sumatriptan Succinate 50 MG TABLET |
2 |
Generic |
$20.00 | $40.00 | Q:18 /28Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
2 |
Generic |
$20.00 | $40.00 | Q:4 /28Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Generic |
$20.00 | $40.00 | Q:18 /28Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | 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 |
$85.00 | $170.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
SURMONTIL 25MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
Surmontil 50mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
SUSTIVA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SUSTIVA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
SUSTIVA 600MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYLATRON 200 MCG KIT |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days |
SYLATRON 300 MCG KIT |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days |
SYLVANT 100 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SYMLINPEN 120 PEN INJECTOR |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:11 /28Days |
SYMLINPEN 60 PEN INJECTOR |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:6 /28Days |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
SYNERCID 500MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
SYNJARDY 5-500 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P Q:28 /28Days |
SYPRINE 250 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |