2019 Medicare Part D Plan Formulary Information |
Health Alliance Medicare POS 10 Rx (HMO-POS) (H1463-019-0)
Benefit Details
|
The Health Alliance Medicare POS 10 Rx (HMO-POS) (H1463-019-0) Formulary Drugs Starting with the Letter S in Williamson County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $155.00 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 |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Specialty Tier |
33% | 33% | None |
SANTYL OINTMENT |
4 |
Non-Preferred Drug |
50% | 50% | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Drug |
50% | 50% | S |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
4 |
Non-Preferred Drug |
50% | 50% | S |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Drug |
50% | 50% | S |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
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% | None |
SEEBRI NEOHALER 15.6 MCG INHAL CAP W/DEV |
4 |
Non-Preferred Drug |
50% | 50% | None |
SELEGILINE HCL 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SELZENTRY 20 MG/ML ORAL SOLN |
5 |
Specialty Tier |
33% | 33% | None |
SELZENTRY 25 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SENSIPAR 30MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SENSIPAR 60MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SERTRALINE 20 MG/ML ORAL CONC |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SERTRALINE HCL 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SERTRALINE HCL 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
2 |
Generic |
$20.00 | $50.00 | None |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] |
2 |
Generic |
$20.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
4 |
Non-Preferred Drug |
50% | 50% | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
4 |
Non-Preferred Drug |
50% | 50% | None |
SEVELAMER CARBONATE 800 MG TAB [RENVELA] |
2 |
Generic |
$20.00 | $50.00 | None |
SEVELAMER HCL 400 MG TABLET [RenaGel] |
2 |
Generic |
$20.00 | $50.00 | None |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
2 |
Generic |
$20.00 | $50.00 | None |
SHAROBEL 0.35 MG TABLET |
2 |
Generic |
$20.00 | $50.00 | None |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
Signifor .3 mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
Signifor .6 mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
SILDENAFIL 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILENOR 3 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SILENOR 6 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
2 |
Generic |
$20.00 | $50.00 | None |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
2 |
Generic |
$20.00 | $50.00 | None |
SILVER SULFADIAZINE 1% CREAM |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SIMVASTATIN 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SIMVASTATIN 5 MG TABLET [Zocor] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SIMVASTATIN 80 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Generic |
$20.00 | $50.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Generic |
$20.00 | $50.00 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
33% | 33% | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
2 |
Generic |
$20.00 | $50.00 | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:6 /30Days |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
33% | 33% | Q:6 /30Days |
SKLICE 0.5% LOTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
SODIUM CHLORIDE 0.45% TUBEX |
2 |
Generic |
$20.00 | $50.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Generic |
$20.00 | $50.00 | None |
SODIUM CHLORIDE 0.9% IV SOLN |
2 |
Generic |
$20.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sodium Chloride 3g/100mL |
2 |
Generic |
$20.00 | $50.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Generic |
$20.00 | $50.00 | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] |
5 |
Specialty Tier |
33% | 33% | None |
SODIUM POLYSTYRENE SULF POWDER |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SOLIFENACIN 10 MG TABLET [VESIcare] |
2 |
Generic |
$20.00 | $50.00 | None |
SOLIFENACIN 5 MG TABLET [VESIcare] |
2 |
Generic |
$20.00 | $50.00 | None |
SOLOXIDE DR 150 MG TABLET DR [Doryx] |
2 |
Generic |
$20.00 | $50.00 | None |
SOLTAMOX 20 MG/10 ML SOLN Solution |
5 |
Specialty Tier |
33% | 33% | None |
SOMATULINE DEPOT 120 MG/0.5 ML |
5 |
Specialty Tier |
33% | 33% | P |
SOMATULINE DEPOT 60 MG/0.2 ML |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMATULINE DEPOT 90 MG/0.3 ML |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SOOLANTRA 1% CREAM |
4 |
Non-Preferred Drug |
50% | 50% | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL 120 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SOTALOL 160 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SOTALOL 240 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SOTALOL 80 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SOTALOL AF 120 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SOTYLIZE 5 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SPIRONOLACTONE 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SPIRONOLACTONE 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SPIRONOLACTONE-HCTZ 25-25 TAB |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SPORANOX 10MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$20.00 | $50.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
SPS 15 GM/60 ML SUSPENSION |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SSD 1% CREAM |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
STAVUDINE 15 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
STAVUDINE 20 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | 33% | None |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
33% | 33% | P |
SUCRALFATE 1GM TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULF-PRED 10-0.23% EYE DROPS |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Generic |
$20.00 | $50.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
2 |
Generic |
$20.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULFAMYLON 8.5% CREAM |
4 |
Non-Preferred Drug |
50% | 50% | None |
SULFASALAZINE 500 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULFASALAZINE DR 500 MG TAB |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULINDAC 150 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
SULINDAC 200 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | None |
Sumatriptan 20 MG/ACTUAT Nasal Spray |
2 |
Generic |
$20.00 | $50.00 | 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 |
2 |
Generic |
$20.00 | $50.00 | Q:4 /30Days |
Sumatriptan 4 mg/0.5 ml inject |
2 |
Generic |
$20.00 | $50.00 | Q:4 /30Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
2 |
Generic |
$20.00 | $50.00 | Q:18 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$20.00 | $50.00 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$20.00 | $50.00 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] |
2 |
Generic |
$20.00 | $50.00 | Q:4 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
2 |
Generic |
$20.00 | $50.00 | Q:6 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | $22.50 | Q:9 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $22.50 | Q:9 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
5 |
Specialty Tier |
33% | 33% | None |
SUPREP BOWEL PREP KIT SOLN RECON |
4 |
Non-Preferred Drug |
50% | 50% | None |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
SYLATRON 200 MCG KIT |
5 |
Specialty Tier |
33% | 33% | None |
SYLATRON 300 MCG KIT |
5 |
Specialty Tier |
33% | 33% | None |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
33% | 33% | None |
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 |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
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 | $117.50 | None |
SYMDEKO 100/150 MG-150 MG TABS |
5 |
Specialty Tier |
33% | 33% | P |
SYMFI 600-300-300 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SYMFI LO 400-300-300 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SYMLINPEN 120 PEN INJECTOR |
4 |
Non-Preferred Drug |
50% | 50% | P |
SYMLINPEN 60 PEN INJECTOR |
4 |
Non-Preferred Drug |
50% | 50% | P |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
33% | 33% | None |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
33% | 33% | None |
SYMPAZAN 5 MG FILM |
4 |
Non-Preferred Drug |
50% | 50% | None |
SYMPROIC 0.2 MG TABLET |
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 |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SYNTHROID 100 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 112 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 125 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 150 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 175 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 200 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 25 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 300 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 50 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 75 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
SYNTHROID 88 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | None |