2019 Medicare Part D Plan Formulary Information |
PriorityMedicare Merit (PPO) (H4875-016-1)
Benefit Details
|
The PriorityMedicare Merit (PPO) (H4875-016-1) Formulary Drugs Starting with the Letter S in Grand Traverse County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $81.00 Deductible: $75 |
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 Drug |
45% | 45% | None |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Specialty Tier |
31% | N/A | Q:4 /28Days |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Preferred Brand |
$42.00 | $105.00 | P |
SANTYL OINTMENT |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
5 |
Specialty Tier |
31% | N/A | S Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
5 |
Specialty Tier |
31% | N/A | S Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days |
SAVAYSA 15 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
SAVAYSA 30 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
SAVAYSA 60 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TABLETS 100MG 60 COUNT BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
SAVELLA TABLETS 25MG 60 COUNT BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Non-Preferred Drug |
45% | 45% | None |
SAVELLA TALBETS 50MG 60 COUNT BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop] |
4 |
Non-Preferred Drug |
45% | 45% | None |
SEGLUROMET 2.5-1,000 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days |
SEGLUROMET 2.5-500 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:120 /30Days |
SEGLUROMET 7.5-1,000 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days |
SEGLUROMET 7.5-500 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELEGILINE HCL 5MG CAPSULE |
2* |
Generic |
$10.00 | $0.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | $0.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
31% | N/A | None |
SELZENTRY 20 MG/ML ORAL SOLN |
5 |
Specialty Tier |
31% | N/A | None |
SELZENTRY 25 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
31% | N/A | None |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
SEMPREX-D 8 MG-60 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
SENSIPAR 30MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | P Q:60 /30Days |
SENSIPAR 60MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEREVENT DIS AER 50MCG |
4 |
Non-Preferred Drug |
45% | 45% | None |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
31% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
31% | N/A | P |
SERTRALINE 20 MG/ML ORAL CONC |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SERTRALINE HCL 100 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SERTRALINE HCL 25 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
5 |
Specialty Tier |
31% | N/A | None |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] |
5 |
Specialty Tier |
31% | N/A | None |
SEVELAMER CARBONATE 800 MG TAB [RENVELA] |
4 |
Non-Preferred Drug |
45% | 45% | None |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .3 mg/mL |
5 |
Specialty Tier |
31% | N/A | P |
Signifor .6 mg/mL |
5 |
Specialty Tier |
31% | N/A | P |
Signifor .9 mg/mL |
5 |
Specialty Tier |
31% | N/A | P |
SILDENAFIL 20 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | P |
Siliq 210 mg/1.5 mL |
5 |
Specialty Tier |
31% | N/A | P Q:3 /28Days |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SILVER SULFADIAZINE 1% CREAM |
2* |
Generic |
$10.00 | $0.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
4 |
Non-Preferred Drug |
45% | 45% | None |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
31% | N/A | P |
SIMPONI 100 MG/ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Specialty Tier |
31% | N/A | P |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Specialty Tier |
31% | N/A | P |
SIMVASTATIN 10 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SIMVASTATIN 20 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SIMVASTATIN 40 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SIMVASTATIN 5 MG TABLET [Zocor] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SIMVASTATIN 80 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
2* |
Generic |
$10.00 | $0.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
31% | N/A | None |
SIROLIMUS 2 MG TABLET [Rapamune] |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:6 /30Days |
SKLICE 0.5% LOTION |
4 |
Non-Preferred Drug |
45% | 45% | Q:117 /14Days |
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT |
5 |
Specialty Tier |
31% | N/A | P Q:2 /84Days |
SODIUM CHLORIDE 0.45% TUBEX |
2* |
Generic |
$10.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2* |
Generic |
$10.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IV SOLN |
2* |
Generic |
$10.00 | $0.00 | None |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] |
5 |
Specialty Tier |
31% | N/A | None |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Specialty Tier |
31% | N/A | None |
SODIUM POLYSTYRENE SULF POWDER |
2* |
Generic |
$10.00 | $0.00 | None |
SOLIFENACIN 10 MG TABLET [VESIcare] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLIFENACIN 5 MG TABLET [VESIcare] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SOLTAMOX 20 MG/10 ML SOLN Solution |
4 |
Non-Preferred Drug |
45% | 45% | None |
SOMATULINE DEPOT 120 MG/0.5 ML |
5 |
Specialty Tier |
31% | N/A | None |
SOMATULINE DEPOT 60 MG/0.2 ML |
5 |
Specialty Tier |
31% | N/A | None |
SOMATULINE DEPOT 90 MG/0.3 ML |
5 |
Specialty Tier |
31% | N/A | None |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOOLANTRA 1% CREAM |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SORIATANE 10MG CAPSULES |
5 |
Specialty Tier |
31% | N/A | None |
SORIATANE 25MG CAPSULES |
5 |
Specialty Tier |
31% | N/A | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2* |
Generic |
$10.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2* |
Generic |
$10.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2* |
Generic |
$10.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2* |
Generic |
$10.00 | $0.00 | None |
SOTALOL 120 MG TABLET [Sorine] |
2* |
Generic |
$10.00 | $0.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2* |
Generic |
$10.00 | $0.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
2* |
Generic |
$10.00 | $0.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2* |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL AF 120 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:8 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:8 /30Days |
SPIRONOLACTONE 100 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SPIRONOLACTONE 25 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SPIRONOLACTONE 50 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TAB |
2* |
Generic |
$10.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:60 /30Days |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:90 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:90 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
31% | N/A | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
31% | N/A | P |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
31% | N/A | P |
SPS 15 GM/60 ML SUSPENSION |
2* |
Generic |
$10.00 | $0.00 | None |
SRONYX 0.10-0.02 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SSD 1% CREAM |
2* |
Generic |
$10.00 | $0.00 | None |
STAVUDINE 15 MG CAPSULE |
2* |
Generic |
$10.00 | $0.00 | None |
STAVUDINE 20 MG CAPSULE |
2* |
Generic |
$10.00 | $0.00 | None |
STAVUDINE CAPSULES 30MG 60 BOT |
2* |
Generic |
$10.00 | $0.00 | None |
STAVUDINE CAPSULES 40MG 60 BOT |
2* |
Generic |
$10.00 | $0.00 | None |
STEGLATRO 15 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:30 /30Days |
STEGLATRO 5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:30 /30Days |
STEGLUJAN 15-100 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
STEGLUJAN 5-100 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
STELARA 45 MG/0.5 ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
31% | N/A | P |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:4 /30Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:84 /28Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2* |
Generic |
$10.00 | $0.00 | None |
STRIANT 30 MG MUCOADHESIVE |
4 |
Non-Preferred Drug |
45% | 45% | P |
STRIBILD TABLET |
5 |
Specialty Tier |
31% | N/A | None |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:4 /30Days |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Drug |
45% | 45% | 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 |
45% | 45% | P Q:90 /30Days |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Drug |
45% | 45% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Drug |
45% | 45% | P Q:90 /30Days |
SUBSYS 1,200 MCG SPRAY |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SUBSYS 100 MCG SPRAY |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SUBSYS 200 MCG SPRAY |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SUBSYS 400 MCG SPRAY |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SUBSYS 800 MCG SPRAY |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
31% | N/A | None |
SUCRALFATE 1GM TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2* |
Generic |
$10.00 | $0.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2* |
Generic |
$10.00 | $0.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
2* |
Generic |
$10.00 | $0.00 | 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 |
2* |
Generic |
$10.00 | $0.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
45% | 45% | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
2* |
Generic |
$10.00 | $0.00 | None |
SULFAMYLON 8.5% CREAM |
4 |
Non-Preferred Drug |
45% | 45% | None |
SULFASALAZINE 500 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SULFASALAZINE DR 500 MG TAB |
2* |
Generic |
$10.00 | $0.00 | None |
SULINDAC 150 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SULINDAC 200 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
Sumatriptan 20 MG/ACTUAT Nasal Spray |
2* |
Generic |
$10.00 | $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 |
2* |
Generic |
$10.00 | $0.00 | Q:4 /30Days |
Sumatriptan 4 mg/0.5 ml inject |
2* |
Generic |
$10.00 | $0.00 | Q:4 /30Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
2* |
Generic |
$10.00 | $0.00 | None |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2* |
Generic |
$10.00 | $0.00 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2* |
Generic |
$10.00 | $0.00 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] |
2* |
Generic |
$10.00 | $0.00 | None |
Sumatriptan 6 mg/0.5 ml vial |
2* |
Generic |
$10.00 | $0.00 | Q:4 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
SUMATRIPTAN SUCC 50 MG TABLET |
2* |
Generic |
$10.00 | $0.00 | None |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2* |
Generic |
$10.00 | $0.00 | None |
SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet] |
4 |
Non-Preferred Drug |
45% | 45% | S Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPRAX 100 MG TABLET CHEWABLE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SUPRAX 400 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SUPRAX 500 MG/5 ML SUSPENSION |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SUPREP BOWEL PREP KIT SOLN RECON |
4 |
Non-Preferred Drug |
45% | 45% | None |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
31% | N/A | P |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
SYEDA 28 TABLET [Zarah] |
2* |
Generic |
$10.00 | $0.00 | None |
SYLATRON 200 MCG KIT |
5 |
Specialty Tier |
31% | 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 |
31% | N/A | P |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
31% | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$42.00 | $105.00 | 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 |
$42.00 | $105.00 | None |
SYMDEKO 100/150 MG-150 MG TABS |
5 |
Specialty Tier |
31% | N/A | P |
SYMFI 600-300-300 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SYMFI LO 400-300-300 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SYMLINPEN 120 PEN INJECTOR |
5 |
Specialty Tier |
31% | N/A | S |
SYMLINPEN 60 PEN INJECTOR |
3 |
Preferred Brand |
$42.00 | $105.00 | S Q:12 /30Days |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMPAZAN 5 MG FILM |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SYMPROIC 0.2 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:30 /30Days |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
31% | N/A | None |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
SYNTHROID 100 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 112 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 125 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 150 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 175 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 200 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 25 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 300 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 50 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 75 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 88 MCG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYPRINE 250 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |