2018 Medicare Part D Plan Formulary Information |
HumanaChoice H5216-054 (PPO) (H5216-054-0)
Benefit Details
|
The HumanaChoice H5216-054 (PPO) (H5216-054-0) Formulary Drugs Starting with the Letter S in Webster County, KY: CMS MA Region 13 which includes: KY Plan Monthly Premium: $47.00 Deductible: $175 |
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 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /30Days |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
SANDOSTATIN LAR DEPOT 10 MG KT |
5 |
Specialty Tier |
29% | N/A | P |
SANDOSTATIN LAR DEPOT 20 MG KT |
5 |
Specialty Tier |
29% | N/A | P |
SANDOSTATIN LAR DEPOT 30 MG KT |
5 |
Specialty Tier |
29% | N/A | P |
SANTYL OINTMENT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:10 /30Days |
SELEGILINE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SELEGILINE HCL 5MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2* |
Generic |
$17.00 | $0.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
29% | N/A | Q:240 /30Days |
SELZENTRY 20 MG/ML ORAL SOLN |
5 |
Specialty Tier |
29% | N/A | Q:920 /30Days |
SELZENTRY 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
29% | N/A | Q:120 /30Days |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:120 /30Days |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SENSIPAR 60MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:60 /30Days |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:120 /30Days |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SEROQUEL XR 150 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days |
SEROQUEL XR 200 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days |
SEROQUEL XR 400 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days |
SEROQUEL XR 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
29% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
29% | N/A | P |
SERTRALINE 20 MG/ML ORAL CONC |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SERTRALINE HCL 100 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:90 /30Days |
SERTRALINE HCL 50 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:90 /30Days |
SETLAKIN 0.15 MG-0.03 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:91 /90Days |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:540 /30Days |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:180 /30Days |
SHAROBEL 0.35 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .3 mg/mL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
Signifor .6 mg/mL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
Signifor .9 mg/mL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SILDENAFIL 20 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days |
SILVER SULFADIAZINE 1% CREAM |
2* |
Generic |
$17.00 | $0.00 | None |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
29% | N/A | P Q:3 /30Days |
SIMPONI 100 MG/ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | P Q:3 /30Days |
SIMULECT 20MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
SIMVASTATIN 10 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 40 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 5 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 80 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:68 /28Days |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:6 /28Days |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
29% | N/A | Q:6 /28Days |
SKELAXIN 800 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days |
SODIUM CHLORIDE 0.45% TUBEX |
2* |
Generic |
$17.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2* |
Generic |
$17.00 | $0.00 | None |
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 |
$17.00 | $0.00 | None |
Sodium Chloride 3g/100mL |
2* |
Generic |
$17.00 | $0.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2* |
Generic |
$17.00 | $0.00 | None |
SODIUM CL 2.5 MEQ/ML VIAL |
2* |
Generic |
$17.00 | $0.00 | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Specialty Tier |
29% | N/A | None |
SODIUM POLYSTYRENE SULF POWDER |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
3 |
Preferred Brand |
$47.00 | $131.00 | S Q:15 /24Days |
SOLTAMOX 20 MG/10 ML SOLN Solution |
5 |
Specialty Tier |
29% | N/A | None |
SOLU MEDROL FOR INJECTION 40 MG/ML |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SOLU MEDROL FOR INJECTION 500 MG/ML |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SOLU-MEDROL 2000MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Solu-Medrol, Preservative Free 1000 MG / 8 ML Vial |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SOMATULINE DEPOT 120 MG/0.5 ML |
5 |
Specialty Tier |
29% | N/A | P Q:1 /28Days |
SOMATULINE DEPOT 60 MG/0.2 ML |
5 |
Specialty Tier |
29% | N/A | P |
SOMATULINE DEPOT 90 MG/0.3 ML |
5 |
Specialty Tier |
29% | N/A | P |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2* |
Generic |
$17.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2* |
Generic |
$17.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2* |
Generic |
$17.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2* |
Generic |
$17.00 | $0.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2* |
Generic |
$17.00 | $0.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
2* |
Generic |
$17.00 | $0.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2* |
Generic |
$17.00 | $0.00 | None |
SOTALOL AF 120 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /28Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 100 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
SPIRONOLACTONE 25 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
SPIRONOLACTONE 50 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TAB |
2* |
Generic |
$17.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:90 /30Days |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:360 /30Days |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:180 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
29% | N/A | 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 |
29% | N/A | P Q:90 /30Days |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
SPS 15 GM/60 ML SUSPENSION |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SRONYX 0.10-0.02 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SSD 1% CREAM |
2* |
Generic |
$17.00 | $0.00 | None |
STALEVO 100 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
STALEVO 125/200 MG/MG TABLETS |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
STALEVO 150 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
STALEVO 18.75/75 MG/MG TABLETS |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
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 |
$100.00 | $290.00 | P |
STALEVO 50 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
STAVUDINE 15 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days |
STAVUDINE 20 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days |
STAVUDINE CAPSULES 30MG 60 BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
STAVUDINE CAPSULES 40MG 60 BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
29% | N/A | P |
STERILE WATER FOR IRRIGATION |
2* |
Generic |
$17.00 | $0.00 | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
5 |
Specialty Tier |
29% | N/A | None |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /28Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:84 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRENSIQ 40 MG/ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
STRENSIQ 80 MG/0.8 ML VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:38 /28Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
29% | N/A | None |
SUCRALFATE 1GM TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2* |
Generic |
$17.00 | $0.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
2* |
Generic |
$17.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP INJ VIAL |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SULFAMYLON 50G PACKET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SULFAMYLON 8.5% CREAM |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SULFASALAZINE 500 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
SULFASALAZINE DR 500 MG TAB |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
SULINDAC 150 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
SULINDAC 200 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 4 MG/0.5 ML CART |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days |
Sumatriptan 4 mg/0.5 ml inject |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | Q:9 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2* |
Generic |
$17.00 | $0.00 | Q:9 /30Days |
SUPRAX 400 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SUPREP BOWEL PREP KIT SOLN RECON |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SUSTIVA 200MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUSTIVA 50MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:480 /30Days |
SUSTIVA 600MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
SYEDA 28 TABLET [Zarah] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
SYLATRON 200 MCG KIT |
5 |
Specialty Tier |
29% | N/A | P Q:4 /28Days |
SYLATRON 300 MCG KIT |
5 |
Specialty Tier |
29% | N/A | P Q:4 /28Days |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
29% | N/A | P Q:4 /28Days |
SYLVANT 100 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYLVANT 400 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$47.00 | $131.00 | 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 |
$47.00 | $131.00 | Q:10 /30Days |
SYMBYAX 12-25MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
SYMBYAX 12-50MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
SYMBYAX 6-25MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
SYMBYAX 6-50MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
SYMFI 600-300-300 MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
SYMFI LO 400-300-300 MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
SYMLINPEN 120 PEN INJECTOR |
5 |
Specialty Tier |
29% | N/A | Q:11 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMLINPEN 60 PEN INJECTOR |
5 |
Specialty Tier |
29% | N/A | Q:11 /28Days |
SYNAGIS 100 MG/1 ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
SYNAGIS 50MG/0.5ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
29% | N/A | None |
SYNERCID 500MG VIAL |
5 |
Specialty Tier |
29% | N/A | None |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
SYNTHROID 100 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 112 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 125 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 150 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 175 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 200 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 25 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 300 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 50 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 75 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYNTHROID 88 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
SYPRINE 250 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | None |