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2017 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-164-0) Benefit Details
The First Health Part D Premier Plus (PDP) (S5768-164-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 5 which includes: DC DE MD Plan Monthly Premium: $125.70 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter S Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter S Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SANDIMMUNE 100MG/ML TUBEX	4	Non-Preferred Drug	50%	50%	P
SANTYL OINTMENT	3	Preferred Brand	$34.00	$102.00	None
SAPHRIS 10 MG TAB SL BLK CHERY	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SAPHRIS 2.5 MG TAB SL BLK CHRY	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SAPHRIS 5 MG TAB SL BLK CHERRY	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SAVAYSA 15 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
SAVAYSA 30 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
SAVAYSA 60 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
SAVELLA TABLETS 100MG 60 COUNT BOT	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SAVELLA TABLETS 25MG 60 COUNT BOT	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM	4	Non-Preferred Drug	50%	50%	P Q:110 /365Days
SAVELLA TALBETS 50MG 60 COUNT BOT	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
SELEGILINE HCL 5 MG TABLET	2	Generic	$2.00	$6.00	None
SELEGILINE HCL 5MG CAPSULE	2	Generic	$2.00	$6.00	None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE	2	Generic	$2.00	$6.00	None
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE	5	Specialty Tier	33%	N/A	Q:60 /30Days
SELZENTRY 25 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:240 /30Days
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE	5	Specialty Tier	33%	N/A	Q:120 /30Days
SELZENTRY 75 MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
SENSIPAR 30MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SENSIPAR 60MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
SENSIPAR 90MG TABLET	5	Specialty Tier	33%	N/A	Q:120 /30Days
SEREVENT DIS AER 50MCG	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN	3	Preferred Brand	$34.00	$102.00	Q:60 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT	3	Preferred Brand	$34.00	$102.00	Q:60 /30Days
SERTRALINE 20 MG/ML ORAL CONC	3	Preferred Brand	$34.00	$102.00	None
SERTRALINE HCL 100 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
SERTRALINE HCL 25 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Sertraline hcl 50 mg tablet	1	Preferred Generic	$1.00	$3.00	None
SETLAKIN 0.15 MG-0.03 MG TAB	2	Generic	$2.00	$6.00	None
Sevelamer Carbonate 26.7 MG/ML Oral Suspension [RENVELA]	3	Preferred Brand	$34.00	$102.00	None
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]	3	Preferred Brand	$34.00	$102.00	None
Sevelamer Carbonate 40 MG/ML Oral Suspension [RENVELA]	3	Preferred Brand	$34.00	$102.00	None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]	3	Preferred Brand	$34.00	$102.00	None
SHAROBEL 0.35 MG TABLET	2	Generic	$2.00	$6.00	None
Signifor .3 mg/mL	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Signifor .6 mg/mL	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Signifor .9 mg/mL	5	Specialty Tier	33%	N/A	P Q:60 /30Days
SILDENAFIL 20 MG TABLET	3	Preferred Brand	$34.00	$102.00	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SILENOR 3 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
SILENOR 6 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
SILVER SULFADIAZINE 1% CRM	2	Generic	$2.00	$6.00	None
SIMBRINZA 1%-0.2% EYE DROPS	4	Non-Preferred Drug	50%	50%	None
SIMULECT 20MG VIAL	5	Specialty Tier	33%	N/A	P
SIMVASTATIN 10 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
SIMVASTATIN 20 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
SIMVASTATIN 40MG TABLET (500 CT)	1	Preferred Generic	$1.00	$3.00	None
SIMVASTATIN 5 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
SIMVASTATIN 80MG TABLET (1000 CT)	1	Preferred Generic	$1.00	$3.00	Q:30 /30Days
Sirolimus 0.5 MG Tablet [Rapamune]	4	Non-Preferred Drug	50%	50%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SIROLIMUS 1 MG TABLET [Rapamune]	4	Non-Preferred Drug	50%	50%	P
SIROLIMUS 2 MG TABLET [Rapamune]	4	Non-Preferred Drug	50%	50%	P
SIRTURO 100 MG TABLET	5	Specialty Tier	33%	N/A	P Q:188 /365Days
SIVEXTRO 200 MG TABLET	5	Specialty Tier	33%	N/A	None
SIVEXTRO 200 MG VIAL	5	Specialty Tier	33%	N/A	None
SODIUM CHLORIDE 0.45% TUBEX	2	Generic	$2.00	$6.00	None
Sodium Chloride 3g/100mL	2	Generic	$2.00	$6.00	None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$3.00	None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG	2	Generic	$2.00	$6.00	None
SODIUM CHLORIDE INJECTION USP 5%	2	Generic	$2.00	$6.00	None
SODIUM CL 2.5 MEQ/ML VIAL	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SODIUM PHENYLBUTYRATE POWDER	5	Specialty Tier	33%	N/A	P
sodium polystyrene sulf pwd	3	Preferred Brand	$34.00	$102.00	None
SOLTAMOX 10 MG/5 ML SOLN	4	Non-Preferred Drug	50%	50%	P
SOMATULINE DEPOT 120 MG/0.5 ML	5	Specialty Tier	33%	N/A	P Q:1 /28Days
SOMATULINE DEPOT 60 MG/0.2 ML	5	Specialty Tier	33%	N/A	P
SOMATULINE DEPOT 90 MG/0.3 ML	5	Specialty Tier	33%	N/A	P
SOMAVERT 10 MG VIAL	5	Specialty Tier	33%	N/A	P
SOMAVERT 15 MG VIAL	5	Specialty Tier	33%	N/A	P
SOMAVERT 20 MG VIAL	5	Specialty Tier	33%	N/A	P
SOMAVERT 25 MG VIAL	5	Specialty Tier	33%	N/A	P
SOMAVERT 30 MG VIAL	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD	1	Preferred Generic	$1.00	$3.00	None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD	1	Preferred Generic	$1.00	$3.00	None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD	1	Preferred Generic	$1.00	$3.00	None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD	1	Preferred Generic	$1.00	$3.00	None
SOTALOL HCL TABLET 240MG	1	Preferred Generic	$1.00	$3.00	None
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$3.00	None
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE	1	Preferred Generic	$1.00	$3.00	None
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$3.00	None
SOVALDI 400 MG TABLET	5	Specialty Tier	33%	N/A	P Q:28 /28Days
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
SPIRIVA RESPIMAT 1.25 MCG INH	3	Preferred Brand	$34.00	$102.00	Q:4 /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	$34.00	$102.00	Q:4 /30Days
SPIRONOLACTONE 100MG TABLET	1	Preferred Generic	$1.00	$3.00	None
SPIRONOLACTONE 25MG TABLET (100 CT)	1	Preferred Generic	$1.00	$3.00	None
SPIRONOLACTONE 50MG TABLET (100 CT)	1	Preferred Generic	$1.00	$3.00	None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)	3	Preferred Brand	$34.00	$102.00	None
SPORANOX 10MG/ML SOLUTION	5	Specialty Tier	33%	N/A	P
SPRINTEC 0.25-0.035 TABLET	2	Generic	$2.00	$6.00	None
SPRITAM 1,000 MG TABLET	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
SPRITAM 250 MG TABLET	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
SPRITAM 500 MG TABLET	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
SPRITAM 750 MG TABLET	4	Non-Preferred Drug	50%	50%	P Q:120 /30Days
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	Specialty Tier	33%	N/A	P Q:30 /30Days
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
SPRYCEL 20MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
SPRYCEL 50MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
SPRYCEL 70MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
SPS 15 GM/60 ML SUSPENSION	3	Preferred Brand	$34.00	$102.00	None
SRONYX 0.10-0.02 MG TABLET	2	Generic	$2.00	$6.00	None
SSD Cream 10g/1000g 85 g in 1 TUBE	2	Generic	$2.00	$6.00	None
STALEVO 100 TABLET	4	Non-Preferred Drug	50%	50%	S
STALEVO 150 TABLET	4	Non-Preferred Drug	50%	50%	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STALEVO 200 50-200-200 TABLET	4	Non-Preferred Drug	50%	50%	S
STAVUDINE CAPSULES 15MG 60 BOT	3	Preferred Brand	$34.00	$102.00	None
STAVUDINE CAPSULES 20MG 60 BOT	3	Preferred Brand	$34.00	$102.00	None
STAVUDINE CAPSULES 30MG 60 BOT	3	Preferred Brand	$34.00	$102.00	None
STAVUDINE CAPSULES 40MG 60 BOT	3	Preferred Brand	$34.00	$102.00	None
STERILE WATER FOR IRRIGATION	2	Generic	$2.00	$6.00	None
STIOLTO RESPIMAT INHAL SPRAY	3	Preferred Brand	$34.00	$102.00	Q:4 /30Days
STIVARGA 40 MG TABLET	5	Specialty Tier	33%	N/A	P Q:120 /30Days
STRATTERA 100MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
STRATTERA 10MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
STRATTERA 18MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STRATTERA 25MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
STRATTERA 40MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
STRATTERA 60MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
STRATTERA 80MG CAPSULE	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
STREPTOMYCIN FOR INJECTION 1GM/VIL	2	Generic	$2.00	$6.00	None
STRIBILD TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
STRIVERDI RESPIMAT INHAL SPRAY	3	Preferred Brand	$34.00	$102.00	Q:4 /30Days
SUBOXONE 12 MG-3 MG SL FILM	4	Non-Preferred Drug	50%	50%	P Q:60 /30Days
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH	4	Non-Preferred Drug	50%	50%	P Q:90 /30Days
SUBOXONE 4 MG-1 MG SL FILM	4	Non-Preferred Drug	50%	50%	P Q:90 /30Days
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH	4	Non-Preferred Drug	50%	50%	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUCRALFATE 1GM TABLET	2	Generic	$2.00	$6.00	None
SULF-PRED 10-0.23% EYE DROPS	2	Generic	$2.00	$6.00	None
SULFACETAMIDE 10% EYE OINTMENT	2	Generic	$2.00	$6.00	None
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE	2	Generic	$2.00	$6.00	None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT	3	Preferred Brand	$34.00	$102.00	None
Sulfadiazine 500mg/1 100 TABLET BOTTLE	2	Generic	$2.00	$6.00	None
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL	3	Preferred Brand	$34.00	$102.00	None
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE	1	Preferred Generic	$1.00	$3.00	None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL	1	Preferred Generic	$1.00	$3.00	None
SULFAMETHOXAZOLE-TMP SS TABLET	1	Preferred Generic	$1.00	$3.00	None
SULFAMYLON CREAM 85GM 4 OZ TUBE	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SULFASALAZINE 500MG TABLET	3	Preferred Brand	$34.00	$102.00	None
SULFASALAZINE DR 500 MG TAB	3	Preferred Brand	$34.00	$102.00	None
SULINDAC 150MG TABLET (100 CT)	2	Generic	$2.00	$6.00	None
SULINDAC 200MG TABLET	2	Generic	$2.00	$6.00	None
Sumatriptan 20 MG/ACTUAT Nasal Spray	2	Generic	$2.00	$6.00	Q:12 /30Days
SUMATRIPTAN 4 MG/0.5 ML CART	4	Non-Preferred Drug	50%	50%	Q:4 /30Days
Sumatriptan 4 mg/0.5 ml inject	4	Non-Preferred Drug	50%	50%	Q:4 /30Days
Sumatriptan 5 MG/ACTUAT Nasal Spray	2	Generic	$2.00	$6.00	Q:12 /30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT	4	Non-Preferred Drug	50%	50%	Q:4 /30Days
SUMATRIPTAN 6 MG/0.5 ML REFILL	4	Non-Preferred Drug	50%	50%	Q:4 /30Days
SUMATRIPTAN 6 MG/0.5 ML SYRNG	2	Generic	$2.00	$6.00	Q:4 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Sumatriptan 6 mg/0.5 ml vial	4	Non-Preferred Drug	50%	50%	Q:4 /30Days
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK	2	Generic	$2.00	$6.00	Q:9 /30Days
Sumatriptan Succinate 50 MG TABLET	2	Generic	$2.00	$6.00	Q:9 /30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD	2	Generic	$2.00	$6.00	Q:9 /30Days
SUMAVEL DOSEPRO 4 MG/0.5 ML	5	Specialty Tier	33%	N/A	Q:4 /30Days
SUMAVEL DOSEPRO 6 MG/0.5 ML	5	Specialty Tier	33%	N/A	Q:4 /30Days
SUPRAX 100 MG TABLET CHEWABLE	4	Non-Preferred Drug	50%	50%	None
SUPRAX 200 MG TABLET CHEWABLE	4	Non-Preferred Drug	50%	50%	None
SUPRAX 400 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
SUPRAX 500 MG/5 ML SUSPENSION	4	Non-Preferred Drug	50%	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 Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUSTIVA 200MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
SUSTIVA 50MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
SUSTIVA 600MG TABLET	4	Non-Preferred Drug	50%	50%	None
SUTENT 12.5MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:90 /30Days
SUTENT 25mg/1 28 CAPSULE BOTTLE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
SUTENT 37.5 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
SUTENT 50MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
SYLATRON 200 MCG KIT	5	Specialty Tier	33%	N/A	P
SYLATRON 300 MCG KIT	5	Specialty Tier	33%	N/A	P
SYLATRON 600 MCG KIT	5	Specialty Tier	33%	N/A	P
SYLVANT 100 MG VIAL	5	Specialty Tier	33%	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	4	Non-Preferred Drug	50%	50%	S 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	4	Non-Preferred Drug	50%	50%	S Q:10 /30Days
SYMLINPEN 120 PEN INJECTOR	4	Non-Preferred Drug	50%	50%	Q:11 /30Days
SYMLINPEN 60 PEN INJECTOR	4	Non-Preferred Drug	50%	50%	Q:6 /30Days
SYNAGIS 50MG/0.5ML VIAL	5	Specialty Tier	33%	N/A	P
SYNAREL 2MG/ML NASAL SPRAY	5	Specialty Tier	33%	N/A	None
SYNERCID 500MG VIAL	5	Specialty Tier	33%	N/A	None
SYNJARDY 12.5-1,000 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SYNJARDY 12.5-500 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SYNJARDY 5-1,000 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
SYNJARDY 5-500 MG TABLET	4	Non-Preferred Drug	50%	50%	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	5	Specialty Tier	33%	N/A	P
SYNTHROID 100MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 112 MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 125MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
Synthroid 137ug/1 90 TABLET BOTTLE	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 150MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 175MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 200MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 25MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 300MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 50MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNTHROID 75MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYNTHROID 88 MCG TABLET	3	Preferred Brand	$34.00	$102.00	None
SYPRINE 250 MG CAPSULE	5	Specialty Tier	33%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D First Health Part D Premier Plus (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $400 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2017 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.