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First Health Part D Value Plus (PDP) (S5768-155-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2825)
Tier 5 (720)
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-155-0)
Benefit Details           
The First Health Part D Value Plus (PDP) (S5768-155-0)
Formulary Drugs Starting with the Letter S
in CMS PDP Region 32 which includes: CA
Plan Monthly Premium: $56.30 Deductible: $0 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 50%50%None
Salagen 7.5mg/1   4 Non-Preferred Drug 50%50%None
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN   5 Specialty Tier 33%N/AQ:4
/28Days
SANDIMMUNE 100MG CAPSULE   4 Non-Preferred Drug 50%50%P
SANDIMMUNE 100MG/ML TUBEX   3 Preferred Brand $47.00$141.00P
SANDIMMUNE 25MG CAPSULE   4 Non-Preferred Drug 50%50%P
SANDIMMUNE 50MG/ML AMPUL   4 Non-Preferred Drug 50%50%P
SANDOSTATIN LAR DEPOT 10 MG KT   5 Specialty Tier 33%N/AP
SANDOSTATIN LAR DEPOT 20 MG KT   5 Specialty Tier 33%N/AP
SANDOSTATIN LAR DEPOT 30 MG KT   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SANTYL OINTMENT   4 Non-Preferred Drug 50%50%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:240
/30Days
SAPHRIS 5 MG TAB SL BLK CHERRY   4 Non-Preferred Drug 50%50%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 50%50%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 50%50%Q:120
/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
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
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]   4 Non-Preferred Drug 50%50%P Q:10
/30Days
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS   4 Non-Preferred Drug 50%50%None
SELEGILINE HCL 5 MG TABLET   2 Generic $2.00$6.00None
SELEGILINE HCL 5MG CAPSULE   2 Generic $2.00$6.00None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   2 Generic $2.00$6.00None
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 33%N/ANone
SELZENTRY 20 MG/ML ORAL SOLN   4 Non-Preferred Drug 50%50%Q:1840
/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/ANone
SELZENTRY 75 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
SENSIPAR 30MG TABLET   3 Preferred Brand $47.00$141.00P 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/AP Q:60
/30Days
SENSIPAR 90MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
SEREVENT DIS AER 50MCG   3 Preferred Brand $47.00$141.00Q:60
/30Days
SERTRALINE 20 MG/ML ORAL CONC   3 Preferred Brand $47.00$141.00Q:300
/30Days
SERTRALINE HCL 100 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
SERTRALINE HCL 25 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
SERTRALINE HCL 50 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
SETLAKIN 0.15 MG-0.03 MG TAB   3 Preferred Brand $47.00$141.00None
SEVELAMER 0.8 GM POWDER PACKET [RENVELA]   3 Preferred Brand $47.00$141.00None
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela]   3 Preferred Brand $47.00$141.00None
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred Brand $47.00$141.00None
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]   3 Preferred Brand $47.00$141.00None
SEVELAMER CARBONATE 800 MG TAB [RENVELA]   3 Preferred Brand $47.00$141.00None
SHAROBEL 0.35 MG TABLET   3 Preferred Brand $47.00$141.00None
SHINGRIX VIAL KIT   3 Preferred Brand $47.00$141.00Q:2
/365Days
Signifor .3 mg/mL   5 Specialty Tier 33%N/AP
Signifor .6 mg/mL   5 Specialty Tier 33%N/AP
Signifor .9 mg/mL   5 Specialty Tier 33%N/AP
Sildenafil 10 mg/12.5 ml vial   5 Specialty Tier 33%N/AP Q:1125
/30Days
SILDENAFIL 20 MG TABLET   3 Preferred Brand $47.00$141.00P Q:90
/30Days
SILENOR 3 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
SILENOR 6 MG TABLET   3 Preferred Brand $47.00$141.00Q: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 $47.00$141.00None
Silver sulfadiazine 10 MG/ML Topical Cream [Silvadene]   4 Non-Preferred Drug 50%50%None
SIMBRINZA 1%-0.2% EYE DROPS   3 Preferred Brand $47.00$141.00None
SIMULECT 20MG VIAL   5 Specialty Tier 33%N/AP
SIMVASTATIN 10 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
SIMVASTATIN 20 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
SIMVASTATIN 40 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
SIMVASTATIN 5 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
SIMVASTATIN 80 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 50%50%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 50%50%None
SINEMET CR 25; 100mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
SINEMET CR 50; 200mg/1; mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
SINGULAIR 10 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SINGULAIR 4 MG TABLET CHEW   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SINGULAIR 4MG GRANULES   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SINGULAIR 5 MG TABLET CHEW   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Sirolimus 0.5 MG Tablet [Rapamune]   4 Non-Preferred Drug 50%50%P
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/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SIVEXTRO 200 MG TABLET   5 Specialty Tier 33%N/ANone
SIVEXTRO 200 MG VIAL   5 Specialty Tier 33%N/ANone
SODIUM CHLORIDE 0.45% TUBEX   3 Preferred Brand $47.00$141.00None
SODIUM CHLORIDE 0.9% IRRIG.   3 Preferred Brand $47.00$141.00None
SODIUM CHLORIDE 0.9% IV SOLN   3 Preferred Brand $47.00$141.00None
Sodium Chloride 3g/100mL   3 Preferred Brand $47.00$141.00None
SODIUM CHLORIDE INJECTION USP 5%   3 Preferred Brand $47.00$141.00None
SODIUM CL 2.5 MEQ/ML VIAL   3 Preferred Brand $47.00$141.00None
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl]   5 Specialty Tier 33%N/AP
SODIUM PHENYLBUTYRATE POWDER [Buphenyl]   5 Specialty Tier 33%N/AP
SODIUM POLYSTYRENE SULF POWDER   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Solodyn 105mg/1   4 Non-Preferred Drug 50%50%S
Solodyn 55mg/1   4 Non-Preferred Drug 50%50%S
Solodyn 80mg/1   4 Non-Preferred Drug 50%50%S
SOLODYN ER 115 MG TABLET   4 Non-Preferred Drug 50%50%S
SOLODYN ER 65 MG TABLET   4 Non-Preferred Drug 50%50%S
SOLTAMOX 20 MG/10 ML SOLN Solution   4 Non-Preferred Drug 50%50%None
SOLU CORTEF 250MG/VIAL INJECTION   4 Non-Preferred Drug 50%50%None
SOLU CORTEF INJECTION 100 MG/VIAL   4 Non-Preferred Drug 50%50%None
SOLU MEDROL FOR INJECTION 500 MG/ML   4 Non-Preferred Drug 50%50%None
Solu-Medrol 125mg/mL 25 VIAL, PATENT DELIVERY SYSTEM in 1 PACKAGE / 2 mL in 1 VIAL, PATENT DELIVERY   4 Non-Preferred Drug 50%50%None
SOLU-MEDROL 2000MG VIAL   4 Non-Preferred Drug 50%50%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 33%N/AP
SOMATULINE DEPOT 60 MG/0.2 ML   5 Specialty Tier 33%N/AP
SOMATULINE DEPOT 90 MG/0.3 ML   5 Specialty Tier 33%N/AP
SOMAVERT 10 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 15 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 20 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 25 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 30 MG VIAL   5 Specialty Tier 33%N/AP
SONATA 10MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SONATA 5MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
SORILUX 0.005% FOAM   4 Non-Preferred Drug 50%50%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 $1.00$3.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SOTALOL 160 MG TABLET [Sorine]   1 Preferred Generic $1.00$3.00None
SOTALOL 240 MG TABLET [Sorine]   1 Preferred Generic $1.00$3.00None
SOTALOL 80 MG TABLET [Sorine]   1 Preferred Generic $1.00$3.00None
SOTALOL AF 120 MG TABLET   2 Generic $2.00$6.00None
SOVALDI 400 MG TABLET   5 Specialty Tier 33%N/AP Q:28
/28Days
SPIRIVA 18 MCG CP-HANDIHALER   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SPIRONOLACTONE 100 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SPIRONOLACTONE 25 MG TABLET   1 Preferred Generic $1.00$3.00None
SPIRONOLACTONE 50 MG TABLET   1 Preferred Generic $1.00$3.00None
SPIRONOLACTONE-HCTZ 25-25 TAB   3 Preferred Brand $47.00$141.00None
SPORANOX 100MG CAPSULE   4 Non-Preferred Drug 50%50%P
SPORANOX 10MG/ML SOLUTION   5 Specialty Tier 33%N/AP
SPRINTEC 0.25-0.035 TABLET   3 Preferred Brand $47.00$141.00None
SPRITAM 1,000 MG TABLET   4 Non-Preferred Drug 50%50%None
SPRITAM 250 MG TABLET   4 Non-Preferred Drug 50%50%None
SPRITAM 500 MG TABLET   4 Non-Preferred Drug 50%50%None
SPRITAM 750 MG TABLET   4 Non-Preferred Drug 50%50%None
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
SPRYCEL 20MG TABLET   5 Specialty Tier 33%N/AP
SPRYCEL 50MG TABLET   5 Specialty Tier 33%N/AP
SPRYCEL 70MG TABLET   5 Specialty Tier 33%N/AP
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
SPS 15 GM/60 ML SUSPENSION   3 Preferred Brand $47.00$141.00None
SRONYX 0.10-0.02 MG TABLET   3 Preferred Brand $47.00$141.00None
SSD 1% CREAM   3 Preferred Brand $47.00$141.00None
STALEVO 100 TABLET   5 Specialty Tier 33%N/AS
STALEVO 150 TABLET   5 Specialty Tier 33%N/AS
STALEVO 200 50-200-200 TABLET   5 Specialty Tier 33%N/AS
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
STALEVO 50 TABLET   4 Non-Preferred Drug 50%50%S
STARLIX 120MG TABLET   4 Non-Preferred Drug 50%50%None
STARLIX 60MG TABLET   4 Non-Preferred Drug 50%50%None
STAVUDINE 15 MG CAPSULE   3 Preferred Brand $47.00$141.00None
STAVUDINE 20 MG CAPSULE   3 Preferred Brand $47.00$141.00None
STAVUDINE CAPSULES 30MG 60 BOT   3 Preferred Brand $47.00$141.00None
STAVUDINE CAPSULES 40MG 60 BOT   3 Preferred Brand $47.00$141.00None
STERILE WATER FOR IRRIGATION   3 Preferred Brand $47.00$141.00None
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY   4 Non-Preferred Drug 50%50%None
STIVARGA 40 MG TABLET   5 Specialty Tier 33%N/AP
STRATTERA 100MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
STRATTERA 10MG CAPSULE   4 Non-Preferred Drug 50%50%Q:120
/30Days
STRATTERA 18MG CAPSULE   4 Non-Preferred Drug 50%50%Q:120
/30Days
STRATTERA 25MG CAPSULE   4 Non-Preferred Drug 50%50%Q:120
/30Days
STRATTERA 40MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
STRATTERA 60MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
STRATTERA 80MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
STREPTOMYCIN FOR INJECTION 1GM/VIL   4 Non-Preferred Drug 50%50%None
STRIANT 30 MG MUCOADHESIVE   4 Non-Preferred Drug 50%50%P Q:60
/30Days
STRIBILD TABLET   5 Specialty Tier 33%N/ANone
STROMECTOL 3MG TABLET   4 Non-Preferred Drug 50%50%None
SUBOXONE 12 MG-3 MG SL FILM   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
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:120
/30Days
SUBOXONE 4 MG-1 MG SL FILM   4 Non-Preferred Drug 50%50%P Q:120
/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:120
/30Days
SUCRALFATE 1GM TABLET   2 Generic $2.00$6.00None
SULAR ER 17 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%None
SULAR ER 34 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%None
SULAR ER 8.5 MG TABLET   4 Non-Preferred Drug 50%50%None
SULF-PRED 10-0.23% EYE DROPS   2 Generic $2.00$6.00None
SULFACETAMIDE 10% EYE OINTMENT   3 Preferred Brand $47.00$141.00None
SULFACETAMIDE SOD 10% TOP SUSP   4 Non-Preferred Drug 50%50%None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   3 Preferred Brand $47.00$141.00None
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 50%50%None
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS]   1 Preferred Generic $1.00$3.00None
SULFAMETHOXAZOLE-TMP INJ VIAL   4 Non-Preferred Drug 50%50%None
SULFAMETHOXAZOLE-TMP SS TABLET [Septra]   1 Preferred Generic $1.00$3.00None
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric]   4 Non-Preferred Drug 50%50%None
SULFAMYLON 50G PACKET   5 Specialty Tier 33%N/ANone
SULFAMYLON 8.5% CREAM   4 Non-Preferred Drug 50%50%None
SULFASALAZINE 500 MG TABLET   3 Preferred Brand $47.00$141.00None
SULFASALAZINE DR 500 MG TAB   3 Preferred Brand $47.00$141.00None
SULINDAC 150 MG TABLET   2 Generic $2.00$6.00None
SULINDAC 200 MG TABLET   2 Generic $2.00$6.00None
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 $2.00$6.00Q: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$6.00Q:12
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 50%50%Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 50%50%Q:4
/30Days
Sumatriptan 6 mg/0.5 ml vial   4 Non-Preferred Drug 50%50%Q:4
/30Days
SUMATRIPTAN SUCC 100 MG TABLET   2 Generic $2.00$6.00Q:9
/30Days
SUMATRIPTAN SUCC 50 MG TABLET   2 Generic $2.00$6.00Q:9
/30Days
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK   2 Generic $2.00$6.00Q:9
/30Days
SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet]   4 Non-Preferred Drug 50%50%Q:9
/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 Drug 50%50%None
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT   4 Non-Preferred Drug 50%50%None
SUPRAX 200 MG TABLET CHEWABLE   4 Non-Preferred Drug 50%50%None
SUPRAX 200 MG/5 ML SUSPENSION   4 Non-Preferred Drug 50%50%None
SUPRAX 400 MG CAPSULE   3 Preferred Brand $47.00$141.00None
SUPRAX 500 MG/5 ML SUSPENSION   3 Preferred Brand $47.00$141.00None
SUPREP BOWEL PREP KIT SOLN RECON   4 Non-Preferred Drug 50%50%None
SUSTIVA 200MG CAPSULE   5 Specialty Tier 33%N/ANone
SUSTIVA 50MG CAPSULE   3 Preferred Brand $47.00$141.00None
SUSTIVA 600MG TABLET   5 Specialty Tier 33%N/ANone
SUTENT 12.5MG CAPSULE   5 Specialty Tier 33%N/AP
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%N/AP
SUTENT 37.5 MG CAPSULE   5 Specialty Tier 33%N/AP
SUTENT 50MG CAPSULE   5 Specialty Tier 33%N/AP
SYEDA 28 TABLET [Zarah]   3 Preferred Brand $47.00$141.00None
SYLATRON 200 MCG KIT   5 Specialty Tier 33%N/AP
SYLATRON 300 MCG KIT   5 Specialty Tier 33%N/AP
SYLATRON 600 MCG KIT   5 Specialty Tier 33%N/AP
SYLVANT 100 MG VIAL   5 Specialty Tier 33%N/AP
SYLVANT 400 MG VIAL   5 Specialty Tier 33%N/AP
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   3 Preferred Brand $47.00$141.00Q: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 $47.00$141.00Q:14
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SYMBYAX 12-25MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SYMBYAX 12-50MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Symbyax 25; 3mg/1; mg/1 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SYMBYAX 6-25MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SYMBYAX 6-50MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
SYMFI 600-300-300 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
SYMFI LO 400-300-300 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
SYMLINPEN 120 PEN INJECTOR   5 Specialty Tier 33%N/AP Q:11
/30Days
SYMLINPEN 60 PEN INJECTOR   5 Specialty Tier 33%N/AP Q:12
/30Days
SYNAGIS 100 MG/1 ML VIAL   5 Specialty Tier 33%N/ANone
SYNAGIS 50MG/0.5ML VIAL   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SYNALAR 0.025% CREAM KIT   4 Non-Preferred Drug 50%50%None
SYNAREL 2MG/ML NASAL SPRAY   5 Specialty Tier 33%N/ANone
SYNDROS 5 MG/ML SOLUTION   5 Specialty Tier 33%N/AP
SYNERCID 500MG VIAL   5 Specialty Tier 33%N/ANone
SYNRIBO 3.5 MG/ML VIAL   5 Specialty Tier 33%N/AP
SYNTHROID 100 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 112 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 125 MCG TABLET   4 Non-Preferred Drug 50%50%None
Synthroid 137ug/1 90 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
SYNTHROID 150 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 175 MCG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SYNTHROID 200 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 25 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 300 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 50 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 75 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYNTHROID 88 MCG TABLET   4 Non-Preferred Drug 50%50%None
SYPRINE 250 MG CAPSULE   5 Specialty Tier 33%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Value 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2018 )

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.