2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 Qualifies for LIS: No |
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 |
Salagen 5mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Salagen 7.5mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN  |
5 |
Specialty Tier |
25% | N/A | Q:4 /28Days |
SANDIMMUNE 100MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
SANDIMMUNE 100MG/ML TUBEX  |
3 |
Preferred Brand |
$46.00 | N/A | P |
SANDIMMUNE 25MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
SANDIMMUNE 50MG/ML AMPUL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
SANDOSTATIN LAR DEPOT 10 MG KT  |
5 |
Specialty Tier |
25% | N/A | P |
SANDOSTATIN LAR DEPOT 20 MG KT  |
5 |
Specialty Tier |
25% | N/A | P |
SANDOSTATIN LAR DEPOT 30 MG KT  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANTYL OINTMENT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SAPHRIS 10 MG TAB SL BLK CHERY  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY  |
4 |
Non-Preferred Drug |
37% | N/A | Q:240 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
SARAFEM 10mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
SAVELLA TABLETS 100MG 60 COUNT BOT  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:110 /365Days |
SAVELLA TALBETS 50MG 60 COUNT BOT  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop] ![Compare how all Medicare Part D PDP plans in LA cover SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:10 /30Days |
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SELEGILINE HCL 5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
SELEGILINE HCL 5MG CAPSULE  |
2* |
Generic |
$3.00 | N/A | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE  |
2* |
Generic |
$3.00 | N/A | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE  |
5 |
Specialty Tier |
25% | N/A | None |
SELZENTRY 20 MG/ML ORAL SOLN  |
4 |
Non-Preferred Drug |
37% | N/A | Q:1840 /30Days |
SELZENTRY 25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:240 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE  |
5 |
Specialty Tier |
25% | N/A | None |
SELZENTRY 75 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SENSIPAR 30MG TABLET  |
3 |
Preferred Brand |
$46.00 | 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 |
25% | N/A | P Q:60 /30Days |
SENSIPAR 90MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
SEREVENT DIS AER 50MCG  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
SERTRALINE 20 MG/ML ORAL CONC  |
3 |
Preferred Brand |
$46.00 | 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:60 /30Days |
SETLAKIN 0.15 MG-0.03 MG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] ![Compare how all Medicare Part D PDP plans in LA cover SEVELAMER 0.8 GM POWDER PACKET [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] ![Compare how all Medicare Part D PDP plans in LA cover SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] ![Compare how all Medicare Part D PDP plans in LA cover SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] ![Compare how all Medicare Part D PDP plans in LA cover SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
SEVELAMER CARBONATE 800 MG TAB [RENVELA] ![Compare how all Medicare Part D PDP plans in LA cover SEVELAMER CARBONATE 800 MG TAB [RENVELA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
SHAROBEL 0.35 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SHINGRIX VIAL KIT  |
3 |
Preferred Brand |
$46.00 | N/A | Q:2 /365Days |
Signifor .3 mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
Signifor .6 mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
Signifor .9 mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
Sildenafil 10 mg/12.5 ml vial  |
5 |
Specialty Tier |
25% | N/A | P Q:1125 /30Days |
SILDENAFIL 20 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:90 /30Days |
SILENOR 3 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
SILENOR 6 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILVER SULFADIAZINE 1% CREAM  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Silver sulfadiazine 10 MG/ML Topical Cream [Silvadene] ![Compare how all Medicare Part D PDP plans in LA cover Silver sulfadiazine 10 MG/ML Topical Cream [Silvadene].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
SIMBRINZA 1%-0.2% EYE DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SIMULECT 20MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SIMVASTATIN 10 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
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 |
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SINEMET 25; 250mg/1; mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SINGULAIR 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
SINGULAIR 4 MG TABLET CHEW  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
SINGULAIR 4MG GRANULES  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
SINGULAIR 5 MG TABLET CHEW  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover Sirolimus 0.5 MG Tablet [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
SIROLIMUS 1 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover SIROLIMUS 1 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover SIROLIMUS 2 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
SIRTURO 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIVEXTRO 200 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
SIVEXTRO 200 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SODIUM CHLORIDE 0.45% TUBEX  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SODIUM CHLORIDE 0.9% IRRIG.  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SODIUM CHLORIDE 0.9% IV SOLN  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Sodium Chloride 3g/100mL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SODIUM CHLORIDE INJECTION USP 5%  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SODIUM CL 2.5 MEQ/ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] ![Compare how all Medicare Part D PDP plans in LA cover SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] ![Compare how all Medicare Part D PDP plans in LA cover SODIUM PHENYLBUTYRATE POWDER [Buphenyl].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
SODIUM POLYSTYRENE SULF POWDER  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Solodyn 105mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | S |
Solodyn 55mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | S |
Solodyn 80mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | S |
SOLODYN ER 115 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
SOLODYN ER 65 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
SOLTAMOX 20 MG/10 ML SOLN Solution  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SOLU CORTEF 250MG/VIAL INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SOLU CORTEF INJECTION 100 MG/VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SOLU MEDROL FOR INJECTION 500 MG/ML  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SOLU-MEDROL 2000MG VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMATULINE DEPOT 120 MG/0.5 ML  |
5 |
Specialty Tier |
25% | N/A | P |
SOMATULINE DEPOT 60 MG/0.2 ML  |
5 |
Specialty Tier |
25% | N/A | P |
SOMATULINE DEPOT 90 MG/0.3 ML  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 10 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 15 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 20 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 25 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SOMAVERT 30 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SONATA 10MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
SONATA 5MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
SORILUX 0.005% FOAM  |
4 |
Non-Preferred Drug |
37% | N/A | S |
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 |
$0.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD  |
1* |
Preferred Generic |
$0.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD  |
1* |
Preferred Generic |
$0.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD  |
1* |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL 160 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 160 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL 240 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 240 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL 80 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 80 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | None |
SOTALOL AF 120 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
SOVALDI 400 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
SPIRONOLACTONE 100 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
SPIRONOLACTONE 25 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 |
SPIRONOLACTONE 50 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
SPIRONOLACTONE-HCTZ 25-25 TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SPORANOX 100MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
SPORANOX 10MG/ML SOLUTION  |
5 |
Specialty Tier |
25% | N/A | P |
SPRINTEC 0.25-0.035 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SPRITAM 1,000 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SPRITAM 250 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SPRITAM 500 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SPRITAM 750 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 20MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 50MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 70MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P |
SPS 15 GM/60 ML SUSPENSION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SRONYX 0.10-0.02 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SSD 1% CREAM  |
3 |
Preferred Brand |
$46.00 | N/A | None |
STALEVO 100 TABLET  |
5 |
Specialty Tier |
25% | N/A | S |
STALEVO 150 TABLET  |
5 |
Specialty Tier |
25% | N/A | S |
STALEVO 200 50-200-200 TABLET  |
5 |
Specialty Tier |
25% | N/A | S |
STALEVO 50 TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STARLIX 120MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
STARLIX 60MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
STAVUDINE 15 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
STAVUDINE 20 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
STAVUDINE CAPSULES 30MG 60 BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
STAVUDINE CAPSULES 40MG 60 BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
STERILE WATER FOR IRRIGATION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY  |
4 |
Non-Preferred Drug |
37% | N/A | None |
STIVARGA 40 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
STRATTERA 100MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
STRATTERA 10MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 18MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
STRATTERA 25MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
STRATTERA 40MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
STRATTERA 60MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
STRATTERA 80MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
STRIANT 30 MG MUCOADHESIVE  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
STRIBILD TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
STROMECTOL 3MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SUBOXONE 12 MG-3 MG SL FILM  |
4 |
Non-Preferred Drug |
37% | N/A | 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 |
37% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBOXONE 4 MG-1 MG SL FILM  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:120 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:120 /30Days |
SUCRALFATE 1GM TABLET  |
2* |
Generic |
$3.00 | N/A | None |
SULAR ER 17 MG TABLET ER 24H  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULAR ER 34 MG TABLET ER 24H  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULAR ER 8.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULF-PRED 10-0.23% EYE DROPS  |
2* |
Generic |
$3.00 | N/A | None |
SULFACETAMIDE 10% EYE OINTMENT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SULFACETAMIDE SOD 10% TOP SUSP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] ![Compare how all Medicare Part D PDP plans in LA cover SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | None |
SULFAMETHOXAZOLE-TMP INJ VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] ![Compare how all Medicare Part D PDP plans in LA cover SULFAMETHOXAZOLE-TMP SS TABLET [Septra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] ![Compare how all Medicare Part D PDP plans in LA cover SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULFAMYLON 50G PACKET  |
5 |
Specialty Tier |
25% | N/A | None |
SULFAMYLON 8.5% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SULFASALAZINE 500 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SULFASALAZINE DR 500 MG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SULINDAC 150 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
SULINDAC 200 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
Sumatriptan 20 MG/ACTUAT Nasal Spray  |
2* |
Generic |
$3.00 | N/A | Q:12 /30Days |
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 |
37% | N/A | Q:4 /30Days |
Sumatriptan 4 mg/0.5 ml inject  |
4 |
Non-Preferred Drug |
37% | N/A | Q:4 /30Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray  |
2* |
Generic |
$3.00 | N/A | Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT  |
4 |
Non-Preferred Drug |
37% | N/A | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT  |
4 |
Non-Preferred Drug |
37% | N/A | Q:4 /30Days |
Sumatriptan 6 mg/0.5 ml vial  |
4 |
Non-Preferred Drug |
37% | N/A | Q:4 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:9 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK  |
2* |
Generic |
$3.00 | N/A | Q:9 /30Days |
SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:9 /30Days |
SUPRAX 100 MG TABLET CHEWABLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
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 Drug |
37% | N/A | None |
SUPRAX 200 MG TABLET CHEWABLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SUPRAX 200 MG/5 ML SUSPENSION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SUPRAX 400 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SUPRAX 500 MG/5 ML SUSPENSION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SUPREP BOWEL PREP KIT SOLN RECON  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SUSTIVA 200MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | None |
SUSTIVA 50MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
SUSTIVA 600MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
SUTENT 12.5MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
SUTENT 25mg/1 28 CAPSULE BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 37.5 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
SUTENT 50MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
SYEDA 28 TABLET [Zarah] ![Compare how all Medicare Part D PDP plans in LA cover SYEDA 28 TABLET [Zarah].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
SYLATRON 200 MCG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
SYLATRON 300 MCG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
SYLATRON 600 MCG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
SYLVANT 100 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SYLVANT 400 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER  |
3 |
Preferred Brand |
$46.00 | N/A | Q:12 /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 |
$46.00 | N/A | Q:14 /30Days |
SYMBYAX 12-25MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMBYAX 12-50MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
SYMBYAX 6-25MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
SYMBYAX 6-50MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
SYMFI 600-300-300 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
SYMFI LO 400-300-300 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
SYMLINPEN 120 PEN INJECTOR  |
5 |
Specialty Tier |
25% | N/A | P Q:11 /30Days |
SYMLINPEN 60 PEN INJECTOR  |
5 |
Specialty Tier |
25% | N/A | P Q:12 /30Days |
SYNAGIS 100 MG/1 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SYNAGIS 50MG/0.5ML VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SYNALAR 0.025% CREAM KIT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNAREL 2MG/ML NASAL SPRAY  |
5 |
Specialty Tier |
25% | N/A | None |
SYNDROS 5 MG/ML SOLUTION  |
5 |
Specialty Tier |
25% | N/A | P |
SYNERCID 500MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
SYNRIBO 3.5 MG/ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
SYNTHROID 100 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 112 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 125 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Synthroid 137ug/1 90 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 150 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 175 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 200 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 25 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 300 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 50 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 75 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYNTHROID 88 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
SYPRINE 250 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | None |