2020 Medicare Part D Plan Formulary Information |
Health Net Ruby Select (HMO) (H0562-103-0)
Benefit Details
|
The Health Net Ruby Select (HMO) (H0562-103-0) Formulary Drugs Starting with the Letter S in Yolo County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $0.00 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 |
Tier 5 |
33% | N/A | None |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SANTYL OINTMENT |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SAPHRIS 10 MG TABLET SL BLACK CHERRY |
5 |
Tier 5 |
33% | N/A | None |
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SAPHRIS 5 MG TABLET SL BLACK CHERRY |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SAVELLA TABLETS 100MG 60 COUNT BOT |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SAVELLA TABLETS 25MG 60 COUNT BOT |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Tier 4 |
$90.00 | $260.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TALBETS 50MG 60 COUNT BOT |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SECUADO 3.8 MG/24 HR PATCH |
5 |
Tier 5 |
33% | N/A | P |
SECUADO 5.7 MG/24 HR PATCH |
5 |
Tier 5 |
33% | N/A | P |
SECUADO 7.6 MG/24 HR PATCH |
5 |
Tier 5 |
33% | N/A | P |
SELEGILINE HCL 5 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SELZENTRY 20 MG/ML ORAL SOLN |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SELZENTRY 25 MG TABLET |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SELZENTRY 75 MG TABLET |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SEMPREX-D 8 MG-60 MG CAPSULE |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Tier 3 |
$37.00 | $101.00 | Q:2 /1Days |
SERTRALINE 20 MG/ML ORAL CONC |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SERTRALINE HCL 100 MG TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SERTRALINE HCL 50 MG TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SETLAKIN 0.15 MG-0.03 MG TAB |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
5 |
Tier 5 |
33% | N/A | None |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER CARBONATE 800 MG TABLET [RENVELA] |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SHAROBEL 0.35 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SHINGRIX VIAL KIT |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Signifor .3 mg/mL |
5 |
Tier 5 |
33% | N/A | None |
Signifor .6 mg/mL |
5 |
Tier 5 |
33% | N/A | None |
Signifor .9 mg/mL |
5 |
Tier 5 |
33% | N/A | None |
SILDENAFIL 20 MG TABLET [Revatio] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
SILIQ 210 MG/1.5 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SILVER SULFADIAZINE 1% CREAM |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMBRINZA 1%-0.2% EYE DROPS |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Tier 5 |
33% | N/A | P |
SIMPONI 100 MG/ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Tier 5 |
33% | N/A | P |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Tier 5 |
33% | N/A | P |
SIMVASTATIN 10 MG TABLET |
6 |
Tier 6 |
$0.00 | $0.00 | Q:1 /1Days |
SIMVASTATIN 20 MG TABLET |
6 |
Tier 6 |
$0.00 | $0.00 | Q:1 /1Days |
SIMVASTATIN 40 MG TABLET |
6 |
Tier 6 |
$0.00 | $0.00 | Q:1 /1Days |
SIMVASTATIN 5 MG TABLET [Zocor] |
6 |
Tier 6 |
$0.00 | $0.00 | Q:1 /1Days |
SIMVASTATIN 80 MG TABLET |
6 |
Tier 6 |
$0.00 | $0.00 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
5 |
Tier 5 |
33% | N/A | P |
SIRTURO 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
SIVEXTRO 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
SIVEXTRO 200 MG VIAL |
5 |
Tier 5 |
33% | N/A | None |
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT |
5 |
Tier 5 |
33% | N/A | P |
SODIUM CHLORIDE 0.45% Sodium Chloride Injection, USP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SODIUM CHLORIDE 0.9% IV SOLN |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SODIUM CHLORIDE 3% IV SOLUTION |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE INJECTION USP 5% |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SODIUM POLYSTYREN SULF 15 G/60 ML ORAL SUSPENSION [SPS] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SODIUM POLYSTYRENE SULF POWDER |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SOLTAMOX 20 MG/10 ML SOLN Solution |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SOMATULINE DEPOT 120 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
SOMATULINE DEPOT 60 MG/0.2 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
SOMATULINE DEPOT 90 MG/0.3 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
SOMAVERT 10 MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
SOMAVERT 15 MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
SOMAVERT 20 MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
SOMAVERT 25 MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 30 MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
SORILUX 0.005% FOAM |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SOTALOL 120 MG TABLET [Sorine] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SOTALOL AF 120 MG TABLET |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL AF 160 MG TABLET [Sorine] |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SOTYLIZE 5 MG/ML ORAL SOLUTION |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SOVALDI 400 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Tier 3 |
$37.00 | $101.00 | Q:1 /1Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRINTEC 0.25-0.035 TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SPRITAM 250 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SPRITAM 500 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SPRITAM 750 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | N/A | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | N/A | P |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPS 15 GM/60 ML SUSPENSION |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SRONYX 0.10-0.02 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SSD 1% CREAM |
2 |
Tier 2 |
$15.00 | $30.00 | None |
STALEVO 100 TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STALEVO 125/200 MG/MG TABLETS |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STALEVO 150 TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STALEVO 200 50-200-200 TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STALEVO 50 TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STAVUDINE 15 MG CAPSULE [Zerit] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
STAVUDINE 20 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STAVUDINE 30 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
STAVUDINE 40 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
STELARA 45 MG/0.5 ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
STELARA 90 MG/ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
4 |
Tier 4 |
$90.00 | $260.00 | None |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Tier 3 |
$37.00 | $101.00 | None |
STIVARGA 40 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
STRIBILD TABLET |
5 |
Tier 5 |
33% | N/A | None |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SUBSYS 1,200 MCG SPRAY |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBSYS 100 MCG SPRAY |
5 |
Tier 5 |
33% | N/A | P Q:16 /1Days |
SUBSYS 200 MCG SPRAY |
5 |
Tier 5 |
33% | N/A | P Q:8 /1Days |
SUBSYS 400 MCG SPRAY |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
SUBSYS 800 MCG SPRAY |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
SUCRAID 8500[iU]/mL |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SUCRALFATE 1GM TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1 |
Tier 1 |
$8.00 | $16.00 | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SULFAMYLON 8.5% CREAM |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SULFASALAZINE 500 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SULINDAC 150 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SULINDAC 200 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SUMATRIPTAN 4 MG/0.5 ML CART |
4 |
Tier 4 |
$90.00 | $260.00 | None |
Sumatriptan 4 mg/0.5 ml inject |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Tier 4 |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SUMATRIPTAN SUCC 100 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
SUNOSI 150 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SUNOSI 75 MG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SUPREP BOWEL PREP KIT SOLN RECON |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Tier 5 |
33% | N/A | None |
SUTENT 37.5 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
SUTENT 50MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
SYEDA 28 TABLET [Zarah] |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYLATRON 200 MCG KIT |
5 |
Tier 5 |
33% | N/A | None |
SYLATRON 300 MCG KIT |
5 |
Tier 5 |
33% | N/A | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYMDEKO 100/150 MG-150 MG TABS |
5 |
Tier 5 |
33% | N/A | P |
SYMDEKO 50/75 MG-75 MG TABLET SEQ |
5 |
Tier 5 |
33% | N/A | P |
SYMFI 600-300-300 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMFI LO 400-300-300 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
SYMLINPEN 120 PEN INJECTOR |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SYMLINPEN 60 PEN INJECTOR |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SYMPAZAN 10 MG FILM |
5 |
Tier 5 |
33% | N/A | P |
SYMPAZAN 20 MG FILM |
5 |
Tier 5 |
33% | N/A | P |
SYMPAZAN 5 MG FILM |
4 |
Tier 4 |
$90.00 | $260.00 | P |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Tier 5 |
33% | N/A | None |
SYNDROS 5 MG/ML SOLUTION |
5 |
Tier 5 |
33% | N/A | P |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYNJARDY 12.5-500 MG TABLET |
3 |
Tier 3 |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY 5-1,000 MG TABLET |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Tier 3 |
$37.00 | $101.00 | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Tier 5 |
33% | N/A | None |
SYNTHROID 100 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 112 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 125 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 150 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 175 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 200 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 25 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 300 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 50 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 75 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |
SYNTHROID 88 MCG TABLET |
4 |
Tier 4 |
$90.00 | $260.00 | None |