2019 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-290-0)
Benefit Details
|
The Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-290-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $21.90 Deductible: $415 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 |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Specialty Tier |
25% | N/A | Q:4 /28Days |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Drug |
49% | 49% | P |
SANTYL OINTMENT |
4 |
Non-Preferred Drug |
49% | 49% | None |
SAPHRIS 10 MG TAB SL BLK CHERY |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
SAPHRIS 2.5 MG TAB SL BLK CHRY |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
SAPHRIS 5 MG TAB SL BLK CHERRY |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop] |
4 |
Non-Preferred Drug |
49% | 49% | Q:10 /30Days |
SELEGILINE HCL 5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
SELEGILINE HCL 5MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SELZENTRY 20 MG/ML ORAL SOLN |
5 |
Specialty Tier |
25% | N/A | Q:1610 /26Days |
SELZENTRY 25 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:240 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SENSIPAR 30MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SENSIPAR 60MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SENSIPAR 90MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
SERTRALINE 20 MG/ML ORAL CONC |
3 |
Preferred Brand |
20% | 20% | Q:300 /30Days |
SERTRALINE HCL 100 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SERTRALINE HCL 25 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
SERTRALINE HCL 50 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:120 /30Days |
SETLAKIN 0.15 MG-0.03 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | Q:91 /91Days |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
4 |
Non-Preferred Drug |
49% | 49% | Q:180 /30Days |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] |
4 |
Non-Preferred Drug |
49% | 49% | Q:180 /30Days |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
20% | 20% | Q:180 /30Days |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
3 |
Preferred Brand |
20% | 20% | Q:180 /30Days |
SEVELAMER CARBONATE 800 MG TAB [RENVELA] |
4 |
Non-Preferred Drug |
49% | 49% | Q:540 /30Days |
SHAROBEL 0.35 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SHINGRIX VIAL KIT |
4 |
Non-Preferred Drug |
49% | 49% | Q:2 /999Days |
Signifor .3 mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Signifor .6 mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Signifor .9 mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SILDENAFIL 20 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P Q:90 /30Days |
SILENOR 3 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
SILENOR 6 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
SILVER SULFADIAZINE 1% CREAM |
4 |
Non-Preferred Drug |
49% | 49% | None |
SIMBRINZA 1%-0.2% EYE DROPS |
4 |
Non-Preferred Drug |
49% | 49% | None |
SIMVASTATIN 10 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
SIMVASTATIN 40 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET [Zocor] |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 80 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
4 |
Non-Preferred Drug |
49% | 49% | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
49% | 49% | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
25% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
49% | 49% | P |
SIRTURO 100 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | P Q:188 /365Days |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:6 /30Days |
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
SODIUM CHLORIDE 0.45% TUBEX |
4 |
Non-Preferred Drug |
49% | 49% | None |
SODIUM CHLORIDE 0.9% IRRIG. |
4 |
Non-Preferred Drug |
49% | 49% | None |
SODIUM CHLORIDE 0.9% IV SOLN |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sodium Chloride 3g/100mL |
4 |
Non-Preferred Drug |
49% | 49% | None |
SODIUM CHLORIDE INJECTION USP 5% |
4 |
Non-Preferred Drug |
49% | 49% | None |
SODIUM LACTATE 5 MEQ/ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | P |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] |
5 |
Specialty Tier |
25% | N/A | P |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Specialty Tier |
25% | N/A | P |
SODIUM POLYSTYRENE SULF POWDER |
3 |
Preferred Brand |
20% | 20% | None |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
3 |
Preferred Brand |
20% | 20% | S Q:18 /30Days |
SOLTAMOX 20 MG/10 ML SOLN Solution |
5 |
Specialty Tier |
25% | N/A | None |
SOMATULINE DEPOT 120 MG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2* |
Generic |
$3.00 | $6.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2* |
Generic |
$3.00 | $6.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2* |
Generic |
$3.00 | $6.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2* |
Generic |
$3.00 | $6.00 | None |
SOTALOL 120 MG TABLET [Sorine] |
2* |
Generic |
$3.00 | $6.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL 240 MG TABLET [Sorine] |
2* |
Generic |
$3.00 | $6.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2* |
Generic |
$3.00 | $6.00 | None |
SOTALOL AF 120 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SPIRIVA 18 MCG CP-HANDIHALER |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
SPIRONOLACTONE 100 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SPIRONOLACTONE 25 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SPIRONOLACTONE 50 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TAB |
2* |
Generic |
$3.00 | $6.00 | None |
SPORANOX 10MG/ML SOLUTION |
5 |
Specialty Tier |
25% | N/A | P |
SPRINTEC 0.25-0.035 TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /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 |
49% | 49% | Q:60 /30Days |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
SPS 15 GM/60 ML SUSPENSION |
3 |
Preferred Brand |
20% | 20% | None |
SRONYX 0.10-0.02 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SSD 1% CREAM |
4 |
Non-Preferred Drug |
49% | 49% | None |
STAVUDINE 15 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
STAVUDINE 20 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
STAVUDINE CAPSULES 30MG 60 BOT |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
STAVUDINE CAPSULES 40MG 60 BOT |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
STRATTERA 100MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
STRATTERA 10MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:60 /30Days |
STRATTERA 18MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:60 /30Days |
STRATTERA 25MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:60 /30Days |
STRATTERA 40MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 60MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
STRATTERA 80MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
4 |
Non-Preferred Drug |
49% | 49% | None |
STRIBILD TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
SUBOXONE 12 MG-3 MG SL FILM |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
SUBOXONE 4 MG-1 MG SL FILM |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
SUCRALFATE 1GM TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2* |
Generic |
$3.00 | $6.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
4 |
Non-Preferred Drug |
49% | 49% | 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 |
$3.00 | $6.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
49% | 49% | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
4 |
Non-Preferred Drug |
49% | 49% | None |
SULFAMYLON 50G PACKET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SULFASALAZINE 500 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SULFASALAZINE DR 500 MG TAB |
2* |
Generic |
$3.00 | $6.00 | None |
SULINDAC 150 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
SULINDAC 200 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Sumatriptan 20 MG/ACTUAT Nasal Spray |
4 |
Non-Preferred Drug |
49% | 49% | 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 |
49% | 49% | Q:8 /30Days |
Sumatriptan 4 mg/0.5 ml inject |
4 |
Non-Preferred Drug |
49% | 49% | Q:8 /30Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
4 |
Non-Preferred Drug |
49% | 49% | Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Non-Preferred Drug |
49% | 49% | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Non-Preferred Drug |
49% | 49% | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] |
4 |
Non-Preferred Drug |
49% | 49% | Q:4 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Non-Preferred Drug |
49% | 49% | Q:4 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:9 /30Days |
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK |
2* |
Generic |
$3.00 | $6.00 | Q:9 /30Days |
SUPREP BOWEL PREP KIT SOLN RECON |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
SYLATRON 200 MCG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
SYLATRON 300 MCG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
SYLATRON 600 MCG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
4 |
Non-Preferred Drug |
49% | 49% | S 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 |
4 |
Non-Preferred Drug |
49% | 49% | S Q:14 /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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMLINPEN 120 PEN INJECTOR |
4 |
Non-Preferred Drug |
49% | 49% | P Q:11 /28Days |
SYMLINPEN 60 PEN INJECTOR |
4 |
Non-Preferred Drug |
49% | 49% | P Q:6 /30Days |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SYMPAZAN 5 MG FILM |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
25% | N/A | P |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
SYNTHROID 100 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 112 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 125 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 150 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 175 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 200 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | 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 |
49% | 49% | None |
SYNTHROID 300 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 50 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 75 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYNTHROID 88 MCG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
SYPRINE 250 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |