2018 Medicare Part D Plan Formulary Information |
SelectHealth Advantage Enhanced (HMO) (H1994-008-0)
Benefit Details
|
The SelectHealth Advantage Enhanced (HMO) (H1994-008-0) Formulary Drugs Starting with the Letter S in Elmore County, ID: CMS MA Region 23 which includes: ID Plan Monthly Premium: $46.00 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 |
Safyral 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SAIZEN 5 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SAIZEN 8.8 MG SAIZENPREP CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P |
SAIZEN 8.8 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Preferred Brand |
$45.00 | N/A | P |
SANTYL OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SAVAYSA 15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVAYSA 30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:30 /30Days |
SAVAYSA 60 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:30 /30Days |
SAVELLA TABLETS 100MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop] |
2 |
Generic |
$10.00 | N/A | Q:10 /28Days |
SEEBRI NEOHALER 15.6 MCG INHAL CAP W/DEV |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SEGLUROMET 2.5-1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SEGLUROMET 2.5-500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEGLUROMET 7.5-1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SEGLUROMET 7.5-500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Generic |
$10.00 | N/A | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
SELZENTRY 20 MG/ML ORAL SOLN |
3 |
Preferred Brand |
$45.00 | N/A | Q:1800 /30Days |
SELZENTRY 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
SELZENTRY 75 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
SEMPREX-D 8 MG-60 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
SENSIPAR 30MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /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 | P Q:120 /30Days |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
SERTRALINE 20 MG/ML ORAL CONC |
2 |
Generic |
$10.00 | N/A | Q:300 /30Days |
SERTRALINE HCL 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
SERTRALINE HCL 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
SEVELAMER CARBONATE 800 MG TAB [RENVELA] |
2 |
Generic |
$10.00 | N/A | None |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
$45.00 | N/A | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SILDENAFIL 20 MG TABLET |
2 |
Generic |
$10.00 | N/A | P Q:90 /30Days |
SILVER SULFADIAZINE 1% CREAM |
2 |
Generic |
$10.00 | N/A | None |
SIMBRINZA 1%-0.2% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:16 /30Days |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
SIMPONI 100 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
SIMPONI ARIA 50 MG/4 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:12 /28Days |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:90 /30Days |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 80 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Generic |
$10.00 | N/A | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Generic |
$10.00 | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
2 |
Generic |
$10.00 | N/A | P |
SIRTURO 100 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:188 /30Days |
SIVEXTRO 200 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:6 /30Days |
SIVEXTRO 200 MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:6 /30Days |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Generic |
$10.00 | N/A | P |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Generic |
$10.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.9% IV SOLN |
2 |
Generic |
$10.00 | N/A | P |
Sodium Chloride 3g/100mL |
2 |
Generic |
$10.00 | N/A | P |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Generic |
$10.00 | N/A | P |
SODIUM CL 2.5 MEQ/ML VIAL |
2 |
Generic |
$10.00 | N/A | P |
SODIUM LACTATE 5 MEQ/ML VIAL |
2 |
Generic |
$10.00 | N/A | P |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
2 |
Generic |
$10.00 | N/A | None |
SODIUM POLYSTYRENE SULF POWDER |
2 |
Generic |
$10.00 | N/A | None |
SOLTAMOX 20 MG/10 ML SOLN Solution |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SOMATULINE DEPOT 120 MG/0.5 ML |
5 |
Specialty Tier |
33% | N/A | P |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Generic |
$10.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Generic |
$10.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2 |
Generic |
$10.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Generic |
$10.00 | N/A | None |
SOTALOL 160 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL 240 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL 80 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL AF 120 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$45.00 | N/A | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$45.00 | N/A | Q:4 /30Days |
SPIRONOLACTONE 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
SPIRONOLACTONE 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
SPIRONOLACTONE 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
SPIRONOLACTONE-HCTZ 25-25 TAB |
2 |
Generic |
$10.00 | N/A | None |
SPORANOX 10MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$10.00 | N/A | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:90 /30Days |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:90 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:90 /30Days |
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:60 /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 |
2 |
Generic |
$10.00 | N/A | None |
SRONYX 0.10-0.02 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
SSD 1% CREAM |
2 |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE 15 MG CAPSULE |
2 |
Generic |
$10.00 | N/A | Q:60 /30Days |
STAVUDINE 20 MG CAPSULE |
2 |
Generic |
$10.00 | N/A | Q:60 /30Days |
STAVUDINE CAPSULES 30MG 60 BOT |
2 |
Generic |
$10.00 | N/A | Q:60 /30Days |
STAVUDINE CAPSULES 40MG 60 BOT |
2 |
Generic |
$10.00 | N/A | Q:60 /30Days |
STEGLATRO 15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
STEGLATRO 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
STELARA 130 MG/26 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:104 /28Days |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /84Days |
STELARA 45 MG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /84Days |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$45.00 | N/A | Q:4 /30Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:84 /21Days |
STRENSIQ 40 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:24 /28Days |
STRENSIQ 80 MG/0.8 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:36 /28Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2 |
Generic |
$10.00 | N/A | P |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$45.00 | N/A | Q:4 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
33% | N/A | P Q:354 /30Days |
SUCRALFATE 1GM TABLET |
2 |
Generic |
$10.00 | N/A | None |
SULF-PRED 10-0.23% EYE DROPS |
2 |
Generic |
$10.00 | N/A | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE SOD 10% TOP SUSP |
2 |
Generic |
$10.00 | N/A | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2 |
Generic |
$10.00 | N/A | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
2 |
Generic |
$10.00 | N/A | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
2 |
Generic |
$10.00 | N/A | None |
SULFAMETHOXAZOLE-TMP INJ VIAL |
2 |
Generic |
$10.00 | N/A | P |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
2 |
Generic |
$10.00 | N/A | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
2 |
Generic |
$10.00 | N/A | None |
SULFASALAZINE 500 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
SULFASALAZINE DR 500 MG TAB |
2 |
Generic |
$10.00 | N/A | None |
SULINDAC 150 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
SULINDAC 200 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sumatriptan 20 MG/ACTUAT Nasal Spray |
2 |
Generic |
$10.00 | N/A | Q:12 /30Days |
SUMATRIPTAN 4 MG/0.5 ML CART |
2 |
Generic |
$10.00 | N/A | Q:4 /30Days |
Sumatriptan 4 mg/0.5 ml inject |
2 |
Generic |
$10.00 | N/A | Q:4 /30Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
2 |
Generic |
$10.00 | N/A | Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$10.00 | N/A | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$10.00 | N/A | Q:4 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
2 |
Generic |
$10.00 | N/A | Q:4 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET |
2 |
Generic |
$10.00 | N/A | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET |
2 |
Generic |
$10.00 | N/A | Q:9 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2 |
Generic |
$10.00 | N/A | Q:9 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SUPRAX 200 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SUPRAX 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
SUPRAX 500 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SUPREP BOWEL PREP KIT SOLN RECON |
4 |
Non-Preferred Brand |
$95.00 | N/A | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYLATRON 300 MCG KIT |
5 |
Specialty Tier |
33% | N/A | P |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
33% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$45.00 | 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 |
3 |
Preferred Brand |
$45.00 | N/A | Q:10 /30Days |
SYMDEKO 100/150 MG-150 MG TABS |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SYMFI 600-300-300 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
SYMFI LO 400-300-300 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
SYMLINPEN 120 PEN INJECTOR |
3 |
Preferred Brand |
$45.00 | N/A | S Q:11 /30Days |
SYMLINPEN 60 PEN INJECTOR |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:11 /30Days |
SYMPROIC 0.2 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
SYNAGIS 100 MG/1 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNAGIS 50MG/0.5ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
SYNERCID 500MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:150 /30Days |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$45.00 | N/A | S Q:60 /30Days |
SYNRIBO 3.5 MG/ML 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 |
SYNTHROID 100 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 112 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 125 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 150 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 175 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 200 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 25 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 300 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 50 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
SYNTHROID 75 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 88 MCG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |