2016 Medicare Part D Plan Formulary Information |
Meridian Prime (HMO) (H5779-002-0)
Benefit Details
|
The Meridian Prime (HMO) (H5779-002-0) Formulary Drugs Starting with the Letter S in Peoria County, IL: CMS MA Region 14 which includes: IL 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 |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SANDIMMUNE 100MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Tier 3 |
$47.00 | $94.00 | P |
SANDIMMUNE 25MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SANDIMMUNE 50MG/ML AMPUL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SANDOSTATIN LAR DEPOT 10 MG KT |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SANDOSTATIN LAR DEPOT 20 MG KT |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SANDOSTATIN LAR DEPOT 30 MG KT |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SANTYL OINTMENT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
3 |
Tier 3 |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SAPHRIS 5 MG TAB SL BLK CHERRY |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SARAFEM 10mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SELEGILINE HCL 5 MG TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Tier 2 |
$5.00 | $10.00 | 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 |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SENSIPAR 30MG TABLET |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SENSIPAR 60MG TABLET |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SENSIPAR 90MG TABLET |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SEROQUEL 100MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SEROQUEL 200MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SEROQUEL 25MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SEROQUEL 300MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SEROQUEL 400MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 50MG TABLET (100 CT) |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SERTRALINE HCL 100MG TABLET (30 CT) |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SERTRALINE HCL 25 MG TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SERTRALINE HCL 50MG TABLET (30 CT) |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Tier 3 |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Tier 3 |
$47.00 | $94.00 | None |
Signifor .3 mg/mL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
Signifor .6 mg/mL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
Signifor .9 mg/mL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SIGNIFOR LAR 20 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SIGNIFOR LAR 40 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SIGNIFOR LAR 60 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SILDENAFIL 20 MG TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | P |
SILENOR 3 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SILENOR 6 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SILVER SULFADIAZINE 1% CRM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Tier 5 |
33% | 33% | P |
SIMULECT 20MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
SIMVASTATIN 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SIMVASTATIN 20 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SIMVASTATIN 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Tier 2 |
$5.00 | $10.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Tier 2 |
$5.00 | $10.00 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
2 |
Tier 2 |
$5.00 | $10.00 | P |
SIRTURO 100 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Tier 2 |
$5.00 | $10.00 | P |
Sodium Chloride 3g/100mL |
2 |
Tier 2 |
$5.00 | $10.00 | P |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
1 |
Tier 1 |
$0.00 | $0.00 | P |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Tier 2 |
$5.00 | $10.00 | P |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
sodium polystyrene sulf pwd |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SOLTAMOX 10 MG/5 ML SOLN |
3 |
Tier 3 |
$47.00 | $94.00 | P |
SOLU CORTEF 250MG/VIAL INJECTION |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SOLU-MEDROL 2000MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | 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 |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SOMATULINE DEPOT 120 MG/0.5 ML |
4 |
Tier 4 |
$100.00 | $200.00 | P |
Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SOMAVERT 10 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SOMAVERT 15 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SOMAVERT 20 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SOTALOL HCL TABLET 240MG |
2 |
Tier 2 |
$5.00 | $10.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$5.00 | $10.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SOVALDI 400 MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SPIRONOLACTONE 100MG TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SPORANOX 10MG/ML SOLUTION |
3 |
Tier 3 |
$47.00 | $94.00 | S |
SPRITAM 1,000 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SPRITAM 250 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SPRITAM 500 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SPRITAM 750 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | 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 |
Tier 5 |
33% | 33% | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | 33% | P |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | 33% | P |
STALEVO 100 TABLET |
3 |
Tier 3 |
$47.00 | $94.00 | None |
STALEVO 125/200 MG/MG TABLETS |
4 |
Tier 4 |
$100.00 | $200.00 | None |
STALEVO 150 TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
3 |
Tier 3 |
$47.00 | $94.00 | None |
STALEVO 200 50-200-200 TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE 1 MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Tier 2 |
$5.00 | $10.00 | None |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Tier 2 |
$5.00 | $10.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Tier 2 |
$5.00 | $10.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Tier 2 |
$5.00 | $10.00 | None |
STERILE WATER FOR IRRIGATION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STIVARGA 40 MG TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | P |
STRATTERA 100MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:30 /30Days |
STRATTERA 10MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:60 /30Days |
STRATTERA 18MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:60 /30Days |
STRATTERA 25MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 40MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:60 /30Days |
STRATTERA 60MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:30 /30Days |
STRATTERA 80MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | Q:30 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
STRIBILD TABLET |
4 |
Tier 4 |
$100.00 | $200.00 | None |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
3 |
Tier 3 |
$47.00 | $94.00 | None |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SUCRALFATE 1GM TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Tier 2 |
$5.00 | $10.00 | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULFASALAZINE 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SULINDAC 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SUMATRIPTAN 5 MG NASAL SPRAY |
2 |
Tier 2 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SUMATRIPTAN 6 MG/0.5 ML REFILL |
2 |
Tier 2 |
$5.00 | $10.00 | None |
Sumatriptan 6 mg/0.5 ml vial |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days |
Sumatriptan Succinate 50 MG TABLET |
2 |
Tier 2 |
$5.00 | $10.00 | Q:9 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
2 |
Tier 2 |
$5.00 | $10.00 | None |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Tier 3 |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 400 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SUPRAX 500 MG/5 ML SUSPENSION |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SURMONTIL 25MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
Surmontil 50mg/1 100 CAPSULE BOTTLE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SUSTIVA 200MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SUSTIVA 50MG CAPSULE |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SUSTIVA 600MG TABLET |
3 |
Tier 3 |
$47.00 | $94.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Tier 5 |
33% | 33% | P |
SUTENT 37.5 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 50MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
SYLATRON 200 MCG KIT |
5 |
Tier 5 |
33% | 33% | None |
SYLATRON 300 MCG KIT |
5 |
Tier 5 |
33% | 33% | None |
SYLATRON 600 MCG KIT |
5 |
Tier 5 |
33% | 33% | None |
SYLVANT 100 MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Tier 3 |
$47.00 | $94.00 | S |
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER |
3 |
Tier 3 |
$47.00 | $94.00 | S |
SYMBYAX 12-25MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SYMBYAX 12-50MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE BOTTLE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SYMBYAX 6-25MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBYAX 6-50MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SYMLINPEN 120 PEN INJECTOR |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SYMLINPEN 60 PEN INJECTOR |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SYNAGIS 50MG/0.5ML VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | P |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SYNERCID 500MG VIAL |
4 |
Tier 4 |
$100.00 | $200.00 | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
SYPRINE 250 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $200.00 | None |