2016 Medicare Part D Plan Formulary Information |
Blue Cross Medicare Advantage Premier (HMO) (H8133-011-0)
Benefit Details
|
The Blue Cross Medicare Advantage Premier (HMO) (H8133-011-0) Formulary Drugs Starting with the Letter S in Liberty County, TX: CMS MA Region 17 which includes: TX Plan Monthly Premium: $29.00 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 |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
SANTYL OINTMENT |
3 |
Preferred Brand |
$39.00 | $132.00 | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Generic |
$6.00 | $33.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Generic |
$6.00 | $33.00 | 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 |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$39.00 | $132.00 | P |
SENSIPAR 60MG TABLET |
3 |
Preferred Brand |
$39.00 | $132.00 | P |
SENSIPAR 90MG TABLET |
3 |
Preferred Brand |
$39.00 | $132.00 | P |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN |
3 |
Preferred Brand |
$39.00 | $132.00 | P Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN |
3 |
Preferred Brand |
$39.00 | $132.00 | P Q:30 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN |
3 |
Preferred Brand |
$39.00 | $132.00 | P Q:60 /30Days |
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN |
3 |
Preferred Brand |
$39.00 | $132.00 | P Q:60 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
3 |
Preferred Brand |
$39.00 | $132.00 | P Q:60 /30Days |
SERTRALINE HCL 100MG TABLET (30 CT) |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SERTRALINE HCL 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:30 /30Days |
SERTRALINE HYDROCHLORIDE 20MG/ML ORAL CONCENTRATE |
2 |
Generic |
$6.00 | $33.00 | Q:300 /30Days |
SETLAKIN 0.15 MG-0.03 MG TAB |
2 |
Generic |
$6.00 | $33.00 | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
5 |
Specialty Tier |
33% | 33% | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
5 |
Specialty Tier |
33% | 33% | None |
SHAROBEL 0.35 MG TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
Signifor .3 mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
Signifor .6 mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
SIGNIFOR LAR 20 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SIGNIFOR LAR 40 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 |
SIGNIFOR LAR 60 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SILDENAFIL 20 MG TABLET |
2 |
Generic |
$6.00 | $33.00 | P Q:90 /30Days |
SILENOR 3 MG TABLET |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:30 /30Days |
SILENOR 6 MG TABLET |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:30 /30Days |
SILVER SULFADIAZINE 1% CRM |
2 |
Generic |
$6.00 | $33.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
3 |
Preferred Brand |
$39.00 | $132.00 | None |
SIMULECT 20MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:45 /30Days |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:60 /30Days |
SIMVASTATIN 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:45 /30Days |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 80MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $15.00 | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Generic |
$6.00 | $33.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Generic |
$6.00 | $33.00 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
5 |
Specialty Tier |
33% | 33% | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Generic |
$6.00 | $33.00 | None |
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$6.00 | $33.00 | None |
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG |
2 |
Generic |
$6.00 | $33.00 | None |
SODIUM PHENYLBUTYRATE POWDER |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
sodium polystyrene sulf pwd |
2 |
Generic |
$6.00 | $33.00 | None |
SOLTAMOX 10 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SOMATULINE 60 MG/0.2 ML SYRING |
5 |
Specialty Tier |
33% | 33% | P |
SOMATULINE DEPOT 120 MG/0.5 ML |
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 |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Generic |
$6.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Generic |
$6.00 | $33.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2 |
Generic |
$6.00 | $33.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Generic |
$6.00 | $33.00 | None |
SOTALOL HCL TABLET 240MG |
2 |
Generic |
$6.00 | $33.00 | None |
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$6.00 | $33.00 | None |
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE |
2 |
Generic |
$6.00 | $33.00 | None |
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$6.00 | $33.00 | None |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 100MG TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
SPIRONOLACTONE 25MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $33.00 | None |
SPIRONOLACTONE 50MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $33.00 | None |
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT) |
2 |
Generic |
$6.00 | $33.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
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 |
$6.00 | $33.00 | None |
SSD Cream 10g/1000g 85 g in 1 TUBE |
2 |
Generic |
$6.00 | $33.00 | None |
STAVUDINE 1 MG/ML SOLUTION |
2 |
Generic |
$6.00 | $33.00 | Q:2400 /30Days |
STAVUDINE CAPSULES 15MG 60 BOT |
2 |
Generic |
$6.00 | $33.00 | Q:60 /30Days |
STAVUDINE CAPSULES 20MG 60 BOT |
2 |
Generic |
$6.00 | $33.00 | Q:60 /30Days |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Generic |
$6.00 | $33.00 | Q:60 /30Days |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Generic |
$6.00 | $33.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 FOR IRRIGATION |
2 |
Generic |
$6.00 | $33.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$39.00 | $132.00 | Q:4 /30Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:84 /28Days |
STRATTERA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:30 /30Days |
STRATTERA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
STRATTERA 18MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
STRATTERA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
STRATTERA 40MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 60MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:30 /30Days |
STRATTERA 80MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:30 /30Days |
STRENSIQ 40 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
STRENSIQ 80 MG/0.8 ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
SUCRALFATE 1GM TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE |
2 |
Generic |
$6.00 | $33.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Generic |
$6.00 | $33.00 | None |
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS |
2 |
Generic |
$6.00 | $33.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL |
2 |
Generic |
$6.00 | $33.00 | None |
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE |
2 |
Generic |
$6.00 | $33.00 | None |
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
SULFASALAZINE 500MG TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
SULFAZINE EC 500MG TABLET DELAYED RELEASE |
2 |
Generic |
$6.00 | $33.00 | None |
SULINDAC 150MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 200MG TABLET |
2 |
Generic |
$6.00 | $33.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:12 /30Days |
SUMATRIPTAN 4 MG/0.5 ML CART |
2 |
Generic |
$6.00 | $33.00 | None |
SUMATRIPTAN 5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$6.00 | $33.00 | None |
SUMATRIPTAN 6 MG/0.5 ML REFILL |
2 |
Generic |
$6.00 | $33.00 | None |
Sumatriptan 6 mg/0.5 ml vial |
2 |
Generic |
$6.00 | $33.00 | None |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2 |
Generic |
$6.00 | $33.00 | Q:18 /30Days |
Sumatriptan Succinate 50 MG TABLET |
2 |
Generic |
$6.00 | $33.00 | Q:18 /30Days |
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE |
2 |
Generic |
$6.00 | $33.00 | None |
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD |
2 |
Generic |
$6.00 | $33.00 | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SUPRAX 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | 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 |
$85.00 | $285.00 | None |
SURMONTIL 100MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
SURMONTIL 25MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
Surmontil 50mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | P |
SUSTIVA 200MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
SUSTIVA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:90 /30Days |
SUSTIVA 600MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 200 MCG KIT |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 300 MCG KIT |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
33% | 33% | P |
SYLVANT 100 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$39.00 | $132.00 | 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 |
$39.00 | $132.00 | Q:10 /30Days |
SYMLINPEN 120 PEN INJECTOR |
3 |
Preferred Brand |
$39.00 | $132.00 | None |
SYMLINPEN 60 PEN INJECTOR |
3 |
Preferred Brand |
$39.00 | $132.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:60 /30Days |
SYNJARDY 5-500 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:120 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNTHROID 100MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 112 MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 125MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 150MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 175MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 200MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 25MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 300MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 50MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 75MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYNTHROID 88 MCG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $285.00 | None |
SYPRINE 250 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |