2016 Medicare Part D Plan Formulary Information |
Gateway Health Medicare Assured Diamond (HMO SNP) (H5932-001-0)
Benefit Details
|
The Gateway Health Medicare Assured Diamond (HMO SNP) (H5932-001-0) Formulary Drugs Starting with the Letter S in Blair County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $35.30 Deductible: $360 |
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/ML TUBEX |
1 |
Tier 1 |
$0.00 | N/A | P |
SANDOSTATIN LAR DEPOT 10 MG KT |
1 |
Tier 1 |
$0.00 | N/A | None |
SANDOSTATIN LAR DEPOT 20 MG KT |
1 |
Tier 1 |
$0.00 | N/A | None |
SANDOSTATIN LAR DEPOT 30 MG KT |
1 |
Tier 1 |
$0.00 | N/A | None |
SANTYL OINTMENT |
1 |
Tier 1 |
$0.00 | N/A | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
1 |
Tier 1 |
$0.00 | N/A | None |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
1 |
Tier 1 |
$0.00 | N/A | None |
SAPHRIS 5 MG TAB SL BLK CHERRY |
1 |
Tier 1 |
$0.00 | N/A | None |
SELEGILINE HCL 5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | Q:120 /30Days |
SENSIPAR 30MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SENSIPAR 60MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SENSIPAR 90MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SEREVENT DIS AER 50MCG |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
1 |
Tier 1 |
$0.00 | N/A | None |
SHAROBEL 0.35 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Signifor .3 mg/mL |
1 |
Tier 1 |
$0.00 | N/A | P |
Signifor .6 mg/mL |
1 |
Tier 1 |
$0.00 | N/A | P |
Signifor .9 mg/mL |
1 |
Tier 1 |
$0.00 | N/A | P |
SILDENAFIL 20 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:90 /30Days |
SILVER SULFADIAZINE 1% CRM |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMULECT 20MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMVASTATIN 10 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMVASTATIN 20 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMVASTATIN 5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SODIUM CHLORIDE 0.45% TUBEX |
1 |
Tier 1 |
$0.00 | N/A | None |
Sodium Chloride 3g/100mL |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM CHLORIDE INJECTION USP 5% |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM CL 2.5 MEQ/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM PHENYLBUTYRATE POWDER |
1 |
Tier 1 |
$0.00 | N/A | P |
sodium polystyrene sulf pwd |
1 |
Tier 1 |
$0.00 | N/A | None |
SOLTAMOX 10 MG/5 ML SOLN |
1 |
Tier 1 |
$0.00 | N/A | None |
SOLU MEDROL FOR INJECTION 40 MG/ML |
1 |
Tier 1 |
$0.00 | N/A | None |
SOLU MEDROL FOR INJECTION 500 MG/ML |
1 |
Tier 1 |
$0.00 | N/A | None |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLU-MEDROL 2000MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
SOMATULINE 60 MG/0.2 ML SYRING |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMATULINE DEPOT 120 MG/0.5 ML |
1 |
Tier 1 |
$0.00 | N/A | P |
Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 10 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 15 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 20 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOTALOL HCL TABLET 240MG |
1 |
Tier 1 |
$0.00 | N/A | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOVALDI 400 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:28 /28Days |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SPIRONOLACTONE 100MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
SPORANOX 10MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SPRITAM 1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRITAM 250 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
SPRITAM 500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
SPRITAM 750 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SPRYCEL 20MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SPRYCEL 50MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SPRYCEL 70MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SRONYX 0.1-0.02 TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE 1 MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE CAPSULES 20MG 60 BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
STERILE WATER FOR IRRIGATION |
1 |
Tier 1 |
$0.00 | N/A | None |
STIOLTO RESPIMAT INHAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | Q:8 /28Days |
STIVARGA 40 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
STRATTERA 100MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
STRATTERA 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
STRATTERA 18MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
STRATTERA 25MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 40MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
STRATTERA 60MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
STRATTERA 80MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
STRIBILD TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SUBOXONE 12 MG-3 MG SL FILM |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SUBOXONE 4 MG-1 MG SL FILM |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SUCRALFATE 1GM TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFACETAMIDE 10% EYE OINTMENT |
1 |
Tier 1 |
$0.00 | N/A | None |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
1 |
Tier 1 |
$0.00 | N/A | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL |
1 |
Tier 1 |
$0.00 | N/A | None |
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFAMETHOXAZOLE-TMP SS TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFASALAZINE 500MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$0.00 | N/A | None |
SULINDAC 150MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
SULINDAC 200MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 20 MG NASAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML REFILL |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
Sumatriptan Succinate 50 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
1 |
Tier 1 |
$0.00 | N/A | Q:9 /30Days |
SURMONTIL 100MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P |
SURMONTIL 25MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P |
Surmontil 50mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
SUSTIVA 50MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
SUSTIVA 600MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SUTENT 12.5MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUTENT 37.5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUTENT 50MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SYLATRON 200 MCG KIT |
1 |
Tier 1 |
$0.00 | N/A | P |
SYLATRON 300 MCG KIT |
1 |
Tier 1 |
$0.00 | N/A | P |
SYLATRON 600 MCG KIT |
1 |
Tier 1 |
$0.00 | N/A | P |
SYLVANT 100 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
1 |
Tier 1 |
$0.00 | N/A | 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 |
1 |
Tier 1 |
$0.00 | N/A | Q:10 /30Days |
SYMLINPEN 120 PEN INJECTOR |
1 |
Tier 1 |
$0.00 | N/A | P |
SYMLINPEN 60 PEN INJECTOR |
1 |
Tier 1 |
$0.00 | N/A | P |
SYNAGIS 50MG/0.5ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SYNAREL 2MG/ML NASAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNERCID 500MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNJARDY 12.5-1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY 5-500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNRIBO 3.5 MG/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SYNTHROID 100MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 112 MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 125MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 150MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 175MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 200MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 25MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 300MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 50MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 75MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNTHROID 88 MCG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYPRINE 250 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P |