2020 Medicare Part D Plan Formulary Information |
Prime Health Complete (HMO D-SNP) (H2926-001-0)
Benefit Details
|
The Prime Health Complete (HMO D-SNP) (H2926-001-0) Formulary Drugs Starting with the Letter S in Beltrami County, MN: CMS MA Region 19 which includes: MN Plan Monthly Premium: $21.80 Deductible: $435 |
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 |
SAIZEN 5 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SAIZEN 8.8 MG SAIZENPREP CARTRIDGE |
1 |
Tier 1 |
$0.00 | N/A | P |
SAIZEN 8.8 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SANTYL OINTMENT |
1 |
Tier 1 |
$0.00 | N/A | None |
SAPHRIS 10 MG TABLET SL BLACK CHERRY |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SAPHRIS 5 MG TABLET SL BLACK CHERRY |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SAVELLA TABLETS 100MG 60 COUNT BOT |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
1 |
Tier 1 |
$0.00 | N/A | None |
SAVELLA TALBETS 50MG 60 COUNT BOT |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
1 |
Tier 1 |
$0.00 | N/A | P Q:10 /30Days |
SECUADO 3.8 MG/24 HR PATCH |
1 |
Tier 1 |
$0.00 | N/A | S Q:30 /30Days |
SECUADO 5.7 MG/24 HR PATCH |
1 |
Tier 1 |
$0.00 | N/A | S Q:30 /30Days |
SECUADO 7.6 MG/24 HR PATCH |
1 |
Tier 1 |
$0.00 | N/A | S Q:30 /30Days |
SELEGILINE HCL 5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SELZENTRY 20 MG/ML ORAL SOLN |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SELZENTRY 75 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SEREVENT DIS AER 50MCG |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
1 |
Tier 1 |
$0.00 | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
1 |
Tier 1 |
$0.00 | N/A | P |
SERTRALINE 20 MG/ML ORAL CONC |
1 |
Tier 1 |
$0.00 | N/A | None |
SERTRALINE HCL 100 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SERTRALINE HCL 50 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SETLAKIN 0.15 MG-0.03 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | Q:91 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
1 |
Tier 1 |
$0.00 | N/A | None |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] |
1 |
Tier 1 |
$0.00 | N/A | None |
SEVELAMER CARBONATE 800 MG TABLET [RENVELA] |
1 |
Tier 1 |
$0.00 | N/A | None |
SEVELAMER HCL 400 MG TABLET [RenaGel] |
1 |
Tier 1 |
$0.00 | N/A | None |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
1 |
Tier 1 |
$0.00 | N/A | None |
SHAROBEL 0.35 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SHINGRIX VIAL KIT |
1 |
Tier 1 |
$0.00 | N/A | Q:2 /365Days |
Signifor .3 mg/mL |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
Signifor .6 mg/mL |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
Signifor .9 mg/mL |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SIKLOS 1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIKLOS 100 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
SILDENAFIL 20 MG TABLET [Revatio] |
1 |
Tier 1 |
$0.00 | N/A | P Q:90 /30Days |
SILENOR 3 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SILENOR 6 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SILIQ 210 MG/1.5 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P |
SILVER SULFADIAZINE 1% CREAM |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMBRINZA 1%-0.2% EYE DROPS |
1 |
Tier 1 |
$0.00 | N/A | None |
SIMPONI 100 MG/ML PEN INJECTOR |
1 |
Tier 1 |
$0.00 | N/A | P |
SIMPONI 100 MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P |
SIMPONI 50 MG/0.5 ML PEN INJEC |
1 |
Tier 1 |
$0.00 | N/A | P |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 10 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 40 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET [Zocor] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SIMVASTATIN 80 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
1 |
Tier 1 |
$0.00 | N/A | P |
SIRTURO 100 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.9% IRRIG. |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM CHLORIDE 0.9% IV SOLN |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM POLYSTYREN SULF 15 G/60 ML ORAL SUSPENSION [SPS] |
1 |
Tier 1 |
$0.00 | N/A | None |
SODIUM POLYSTYRENE SULF POWDER |
1 |
Tier 1 |
$0.00 | N/A | None |
SOFOSBUVIR-VELPATASVIR 400-100 TABLET [Epclusa] |
1 |
Tier 1 |
$0.00 | N/A | P Q:28 /28Days |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
1 |
Tier 1 |
$0.00 | N/A | S Q:30 /30Days |
SOLTAMOX 20 MG/10 ML SOLN Solution |
1 |
Tier 1 |
$0.00 | N/A | None |
SOMATULINE DEPOT 120 MG/0.5 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P Q:1 /28Days |
SOMATULINE DEPOT 60 MG/0.2 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P Q:1 /28Days |
SOMATULINE DEPOT 90 MG/0.3 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 10 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 15 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 20 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 25 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SOMAVERT 30 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | N/A | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Tier 1 |
$0.00 | N/A | None |
SOTALOL 120 MG TABLET [Sorine] |
1 |
Tier 1 |
$0.00 | N/A | None |
SOTALOL 160 MG TABLET [Sorine] |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL 240 MG TABLET [Sorine] |
1 |
Tier 1 |
$0.00 | N/A | None |
SOTALOL 80 MG TABLET [Sorine] |
1 |
Tier 1 |
$0.00 | N/A | None |
SOTALOL AF 120 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SOTALOL AF 160 MG TABLET [Sorine] |
1 |
Tier 1 |
$0.00 | N/A | None |
SOTALOL AF 80 MG TABLET [Sorine] |
1 |
Tier 1 |
$0.00 | N/A | None |
SOVALDI 150 MG PELLET PACKET |
1 |
Tier 1 |
$0.00 | N/A | P Q:28 /28Days |
SOVALDI 200 MG PELLET PACKET |
1 |
Tier 1 |
$0.00 | N/A | P Q:56 /28Days |
SOVALDI 400 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:28 /28Days |
SPIRIVA 18 MCG CP-HANDIHALER |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
1 |
Tier 1 |
$0.00 | N/A | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1 |
Tier 1 |
$0.00 | N/A | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
1 |
Tier 1 |
$0.00 | N/A | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SPRITAM 1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SPRITAM 250 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:120 /30Days |
SPRITAM 500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:120 /30Days |
SPRITAM 750 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SPRYCEL 20MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 50MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SPRYCEL 70MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SPS 15 GM/60 ML SUSPENSION |
1 |
Tier 1 |
$0.00 | N/A | None |
SRONYX 0.10-0.02 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SSD 1% CREAM |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE 15 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE 20 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE 30 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$0.00 | N/A | None |
STAVUDINE 40 MG CAPSULE [Zerit] |
1 |
Tier 1 |
$0.00 | N/A | None |
STELARA 45 MG/0.5 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STELARA 45 MG/0.5 ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
STELARA 90 MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
1 |
Tier 1 |
$0.00 | N/A | P |
STIOLTO RESPIMAT INHAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | None |
STIVARGA 40 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:84 /28Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Tier 1 |
$0.00 | N/A | None |
STRIBILD TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
STRIVERDI RESPIMAT INHAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
SUCRALFATE 1GM TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SULF-PRED 10-0.23% EYE DROPS |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE 10% EYE OINTMENT |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFACETAMIDE SOD 10% TOP SUSP |
1 |
Tier 1 |
$0.00 | N/A | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFASALAZINE 500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
1 |
Tier 1 |
$0.00 | N/A | None |
SULINDAC 150 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SULINDAC 200 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Sumatriptan 20 MG/ACTUAT Nasal Spray |
1 |
Tier 1 |
$0.00 | N/A | 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 inject |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
Sumatriptan 6 mg/0.5 ml vial |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
SUMATRIPTAN SUCC 100 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:9 /30Days |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
SUNOSI 150 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUNOSI 75 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPREP BOWEL PREP KIT SOLN RECON |
1 |
Tier 1 |
$0.00 | N/A | None |
SUTENT 12.5MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUTENT 37.5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SUTENT 50MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
SYEDA 28 TABLET [Zarah] |
1 |
Tier 1 |
$0.00 | N/A | None |
SYLATRON 200 MCG KIT |
1 |
Tier 1 |
$0.00 | N/A | P |
SYLATRON 300 MCG KIT |
1 |
Tier 1 |
$0.00 | N/A | P |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
1 |
Tier 1 |
$0.00 | N/A | Q:10 /30Days |
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER |
1 |
Tier 1 |
$0.00 | N/A | Q:10 /30Days |
SYMDEKO 100/150 MG-150 MG TABS |
1 |
Tier 1 |
$0.00 | N/A | P Q:56 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMDEKO 50/75 MG-75 MG TABLET SEQ |
1 |
Tier 1 |
$0.00 | N/A | P Q:56 /28Days |
SYMFI 600-300-300 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYMFI LO 400-300-300 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
SYMJEPI 0.15 MG/0.3 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SYMJEPI 0.3 MG/0.3 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /30Days |
SYMLINPEN 120 PEN INJECTOR |
1 |
Tier 1 |
$0.00 | N/A | P Q:11 /28Days |
SYMLINPEN 60 PEN INJECTOR |
1 |
Tier 1 |
$0.00 | N/A | P Q:11 /28Days |
SYMPAZAN 10 MG FILM |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SYMPAZAN 20 MG FILM |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SYMPAZAN 5 MG FILM |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
SYMTUZA 800-150-200-10 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNAREL 2MG/ML NASAL SPRAY |
1 |
Tier 1 |
$0.00 | N/A | None |
SYNJARDY 12.5-1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
1 |
Tier 1 |
$0.00 | N/A | S Q:30 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
1 |
Tier 1 |
$0.00 | N/A | S Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
1 |
Tier 1 |
$0.00 | N/A | S Q:60 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |