2020 Medicare Part D Plan Formulary Information |
Network Health Medicare Go (PPO) (H5215-009-0)
Benefit Details
|
The Network Health Medicare Go (PPO) (H5215-009-0) Formulary Drugs Starting with the Letter S in Washington County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $0.00 Deductible: $275 |
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 |
Tier 4 |
$84.00 | $210.00 | None |
SAIZEN 5 MG VIAL |
5 |
Tier 5 |
27% | N/A | P |
SAIZEN 8.8 MG SAIZENPREP CARTRIDGE |
5 |
Tier 5 |
27% | N/A | P |
SAIZEN 8.8 MG VIAL |
5 |
Tier 5 |
27% | N/A | P |
SALAGEN 5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SALAGEN 7.5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Tier 5 |
27% | N/A | Q:4 /28Days |
SANDIMMUNE 100MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SANDIMMUNE 25MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SANDOSTATIN 0.05MG/ML AMPUL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Sandostatin 100ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
5 |
Tier 5 |
27% | N/A | None |
Sandostatin 500ug/mL 10 AMPULE in 1 PACKAGE / 1 mL in 1 AMPULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SANTYL OINTMENT |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SAPHRIS 10 MG TABLET SL BLACK CHERRY |
5 |
Tier 5 |
27% | N/A | S |
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY |
5 |
Tier 5 |
27% | N/A | S |
SAPHRIS 5 MG TABLET SL BLACK CHERRY |
5 |
Tier 5 |
27% | N/A | S |
SARAFEM 10mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SARAFEM 20mg/1 72 CARTON in 1 CASE / 4 BLISTER PACK per CARTON / 7 TABLET per BLISTER PACK |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SAVAYSA 15 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SAVAYSA 30 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVAYSA 60 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SECUADO 3.8 MG/24 HR PATCH |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
SECUADO 5.7 MG/24 HR PATCH |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
SECUADO 7.6 MG/24 HR PATCH |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEEBRI NEOHALER 15.6 MCG INHAL CAPSULE W/DEV |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SEGLUROMET 2.5-1,000 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:60 /30Days |
SEGLUROMET 2.5-500 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:120 /30Days |
SEGLUROMET 7.5-1,000 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:60 /30Days |
SEGLUROMET 7.5-500 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Tier 5 |
27% | N/A | None |
SELZENTRY 20 MG/ML ORAL SOLN |
5 |
Tier 5 |
27% | N/A | None |
SELZENTRY 25 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | 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 |
5 |
Tier 5 |
27% | N/A | None |
SELZENTRY 75 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SEMPREX-D 8 MG-60 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SENSIPAR 30MG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | P Q:60 /30Days |
SENSIPAR 60MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
SENSIPAR 90MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
SEREVENT DIS AER 50MCG |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SEROQUEL 100MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:90 /30Days |
SEROQUEL 200MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:90 /30Days |
SEROQUEL 25MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:120 /30Days |
SEROQUEL 300MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEROQUEL 400MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SEROQUEL 50MG TABLET (100 CT) |
4 |
Tier 4 |
$84.00 | $210.00 | Q:90 /30Days |
SEROQUEL XR 150 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:30 /30Days |
SEROQUEL XR 200 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:30 /30Days |
SEROQUEL XR 300MG TABLET 60X300MG BOT |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:60 /30Days |
SEROQUEL XR 400 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:60 /30Days |
SEROQUEL XR 50 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:60 /30Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Tier 5 |
27% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Tier 5 |
27% | N/A | P |
SERTRALINE 20 MG/ML ORAL CONC |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SERTRALINE HCL 100 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SERTRALINE HCL 25 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SETLAKIN 0.15 MG-0.03 MG TAB |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
5 |
Tier 5 |
27% | N/A | None |
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela] |
5 |
Tier 5 |
27% | N/A | None |
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA] |
5 |
Tier 5 |
27% | N/A | None |
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA] |
5 |
Tier 5 |
27% | N/A | None |
SEVELAMER CARBONATE 800 MG TABLET [RENVELA] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SEVELAMER HCL 400 MG TABLET [RenaGel] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SHAROBEL 0.35 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SHINGRIX VIAL KIT |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Signifor .3 mg/mL |
5 |
Tier 5 |
27% | N/A | None |
Signifor .6 mg/mL |
5 |
Tier 5 |
27% | N/A | None |
Signifor .9 mg/mL |
5 |
Tier 5 |
27% | N/A | None |
SIKLOS 1,000 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SIKLOS 100 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio] |
5 |
Tier 5 |
27% | N/A | P |
SILDENAFIL 20 MG TABLET [Revatio] |
3* |
Tier 3 |
$42.00 | $105.00 | P |
SILENOR 3 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SILENOR 6 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SILIQ 210 MG/1.5 ML SYRINGE |
5 |
Tier 5 |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SILVER SULFADIAZINE 1% CREAM |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Silver sulfadiazine 10 MG/ML Topical Cream [Silvadene] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Tier 5 |
27% | N/A | P Q:1 /28Days |
SIMPONI 100 MG/ML SYRINGE |
5 |
Tier 5 |
27% | N/A | P Q:1 /28Days |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Tier 5 |
27% | N/A | P Q:1 /28Days |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Tier 5 |
27% | N/A | P Q:1 /28Days |
SIMVASTATIN 10 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SIMVASTATIN 20 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 40 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SIMVASTATIN 5 MG TABLET [Zocor] |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SIMVASTATIN 80 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SINEMET 10; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SINEMET 25; 100mg/1; mg/1 100 TABLET BOTTLE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SINEMET 25; 250mg/1; mg/1 100 TABLET BOTTLE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SINGULAIR 10 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SINGULAIR 4 MG TABLET CHEW |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SINGULAIR 4MG GRANULES |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SINGULAIR 5 MG TABLET CHEW |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
2* |
Tier 2 |
$8.00 | $20.00 | 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 |
$8.00 | $20.00 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
2* |
Tier 2 |
$8.00 | $20.00 | P |
SIRTURO 100 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SIVEXTRO 200 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SIVEXTRO 200 MG VIAL |
5 |
Tier 5 |
27% | N/A | None |
SKELAXIN 800 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SKLICE 0.5% LOTION |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT |
5 |
Tier 5 |
27% | N/A | P Q:1 /28Days |
SLYND 4 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SODIUM CHLORIDE 0.45% Sodium Chloride Injection, USP |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.9% IRRIG. |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SODIUM CHLORIDE 0.9% IV SOLN |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SODIUM CHLORIDE 3% IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] |
5 |
Tier 5 |
27% | N/A | None |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Tier 5 |
27% | N/A | None |
SODIUM POLYSTYREN SULF 15 G/60 ML ORAL SUSPENSION [SPS] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SODIUM POLYSTYRENE SULF POWDER |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOFOSBUVIR-VELPATASVIR 400-100 TABLET [Epclusa] |
5 |
Tier 5 |
27% | N/A | P Q:28 /28Days |
SOLIFENACIN 10 MG TABLET [VESIcare] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOLIFENACIN 5 MG TABLET [VESIcare] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
3* |
Tier 3 |
$42.00 | $105.00 | Q:15 /25Days |
Solodyn 105mg/1 |
5 |
Tier 5 |
27% | N/A | None |
Solodyn 55mg/1 |
5 |
Tier 5 |
27% | N/A | None |
Solodyn 80mg/1 |
5 |
Tier 5 |
27% | N/A | None |
SOLODYN ER 115 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SOLODYN ER 65 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SOLOSEC 2 GM GRANULE PACKET GRANDR PKT |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SOLTAMOX 20 MG/10 ML SOLN Solution |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SOMA 250 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SOMA 350MG TABLETS |
4 |
Tier 4 |
$84.00 | $210.00 | P |
SOMATULINE DEPOT 120 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMATULINE DEPOT 60 MG/0.2 ML SYRINGE |
5 |
Tier 5 |
27% | N/A | None |
SOMATULINE DEPOT 90 MG/0.3 ML SYRINGE |
5 |
Tier 5 |
27% | N/A | None |
SOMAVERT 10 MG VIAL |
5 |
Tier 5 |
27% | N/A | None |
SOMAVERT 15 MG VIAL |
5 |
Tier 5 |
27% | N/A | None |
SOMAVERT 20 MG VIAL |
5 |
Tier 5 |
27% | N/A | None |
SOMAVERT 25 MG VIAL |
5 |
Tier 5 |
27% | N/A | None |
SOMAVERT 30 MG VIAL |
5 |
Tier 5 |
27% | N/A | None |
SOOLANTRA 1% CREAM |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SORIATANE 10MG CAPSULES |
5 |
Tier 5 |
27% | N/A | None |
SORIATANE 25MG CAPSULES |
5 |
Tier 5 |
27% | N/A | None |
SORILUX 0.005% FOAM |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL 120 MG TABLET [Sorine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL AF 120 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL AF 160 MG TABLET [Sorine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTYLIZE 5 MG/ML ORAL SOLUTION |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SOVALDI 150 MG PELLET PACKET |
5 |
Tier 5 |
27% | N/A | P Q:28 /28Days |
SOVALDI 200 MG PELLET PACKET |
5 |
Tier 5 |
27% | N/A | P Q:56 /28Days |
SOVALDI 400 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:28 /28Days |
SPIRIVA 18 MCG CP-HANDIHALER |
3* |
Tier 3 |
$42.00 | $105.00 | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3* |
Tier 3 |
$42.00 | $105.00 | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3* |
Tier 3 |
$42.00 | $105.00 | Q:4 /30Days |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
1* |
Tier 1 |
$2.00 | $0.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPORANOX 100MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P |
SPORANOX 10MG/ML SOLUTION |
5 |
Tier 5 |
27% | N/A | P |
SPRINTEC 0.25-0.035 TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SPRITAM 250 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SPRITAM 500 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SPRITAM 750 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:90 /30Days |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
SPS 15 GM/60 ML SUSPENSION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SRONYX 0.10-0.02 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SSD 1% CREAM |
2* |
Tier 2 |
$8.00 | $20.00 | None |
STALEVO 100 TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STALEVO 125/200 MG/MG TABLETS |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STALEVO 150 TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STALEVO 18.75/75 MG/MG TABLETS |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STALEVO 200 50-200-200 TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STALEVO 50 TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STARLIX 120MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:90 /30Days |
STARLIX 60MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:180 /30Days |
STAVUDINE 15 MG CAPSULE [Zerit] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
STAVUDINE 20 MG CAPSULE [Zerit] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
STAVUDINE 30 MG CAPSULE [Zerit] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
STAVUDINE 40 MG CAPSULE [Zerit] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
STEGLATRO 15 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:30 /30Days |
STEGLATRO 5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:60 /30Days |
STEGLUJAN 15-100 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:30 /30Days |
STEGLUJAN 5-100 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:30 /30Days |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
27% | 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 |
5 |
Tier 5 |
27% | N/A | P |
STELARA 90 MG/ML SYRINGE |
5 |
Tier 5 |
27% | N/A | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Tier 5 |
27% | N/A | P |
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY |
3* |
Tier 3 |
$42.00 | $105.00 | None |
STIOLTO RESPIMAT INHAL SPRAY |
3* |
Tier 3 |
$42.00 | $105.00 | Q:4 /30Days |
STIVARGA 40 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:112 /28Days |
STRATTERA 100MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STRATTERA 10MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STRATTERA 18MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STRATTERA 25MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STRATTERA 40MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRATTERA 60MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STRATTERA 80MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
STRIBILD TABLET |
5 |
Tier 5 |
27% | N/A | None |
STRIVERDI RESPIMAT INHAL SPRAY |
4 |
Tier 4 |
$84.00 | $210.00 | Q:4 /30Days |
STROMECTOL 3MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Tier 4 |
$84.00 | $210.00 | Q:360 /30Days |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Tier 4 |
$84.00 | $210.00 | Q:90 /30Days |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Tier 4 |
$84.00 | $210.00 | Q:90 /30Days |
SUBSYS 1,200 MCG SPRAY |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBSYS 100 MCG SPRAY |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
SUBSYS 200 MCG SPRAY |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
SUBSYS 400 MCG SPRAY |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
SUBSYS 800 MCG SPRAY |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Tier 5 |
27% | N/A | None |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SUCRALFATE 1GM TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULAR ER 17 MG TABLET ER 24H |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SULAR ER 34 MG TABLET ER 24H |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SULAR ER 8.5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULFAMYLON 50G PACKET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SULFAMYLON 8.5% CREAM |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SULFASALAZINE 500 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 150 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SULINDAC 200 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Sumatriptan 20 MG/ACTUAT Nasal Spray |
4 |
Tier 4 |
$84.00 | $210.00 | Q:12 /30Days |
SUMATRIPTAN 4 MG/0.5 ML CART |
3* |
Tier 3 |
$42.00 | $105.00 | Q:8 /28Days |
Sumatriptan 4 mg/0.5 ml inject |
3* |
Tier 3 |
$42.00 | $105.00 | Q:8 /28Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
4 |
Tier 4 |
$84.00 | $210.00 | Q:36 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
3* |
Tier 3 |
$42.00 | $105.00 | Q:8 /28Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
3* |
Tier 3 |
$42.00 | $105.00 | Q:8 /28Days |
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] |
3* |
Tier 3 |
$42.00 | $105.00 | Q:8 /28Days |
Sumatriptan 6 mg/0.5 ml vial |
3* |
Tier 3 |
$42.00 | $105.00 | Q:8 /28Days |
SUMATRIPTAN SUCC 100 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
2* |
Tier 2 |
$8.00 | $20.00 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2* |
Tier 2 |
$8.00 | $20.00 | Q:9 /30Days |
SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet] |
2* |
Tier 2 |
$8.00 | $20.00 | Q:18 /30Days |
SUNOSI 150 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:30 /30Days |
SUNOSI 75 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:30 /30Days |
SUPRAX 100 MG TABLET CHEWABLE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUPRAX 200 MG TABLET CHEWABLE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUPRAX 200 MG/5 ML SUSPENSION |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUPRAX 400 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUPRAX 500 MG/5 ML SUSPENSION |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUPREP BOWEL PREP KIT SOLN RECON |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUSTIVA 200MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUSTIVA 50MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUSTIVA 600MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Tier 5 |
27% | N/A | Q:28 /28Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Tier 5 |
27% | N/A | Q:28 /28Days |
SUTENT 37.5 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | Q:56 /28Days |
SUTENT 50MG CAPSULE |
5 |
Tier 5 |
27% | N/A | Q:28 /28Days |
SYEDA 28 TABLET [Zarah] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
SYLATRON 200 MCG KIT |
5 |
Tier 5 |
27% | N/A | None |
SYLATRON 300 MCG KIT |
5 |
Tier 5 |
27% | N/A | 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 |
4 |
Tier 4 |
$84.00 | $210.00 | S 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 |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:10 /30Days |
SYMBYAX 12-50MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | S |
Symbyax 25; 3mg/1; mg/1 30 CAPSULE BOTTLE |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SYMBYAX 6-25MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SYMBYAX 6-50MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | S |
SYMDEKO 100/150 MG-150 MG TABS |
5 |
Tier 5 |
27% | N/A | P |
SYMDEKO 50/75 MG-75 MG TABLET SEQ |
5 |
Tier 5 |
27% | N/A | P |
SYMFI 600-300-300 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SYMFI LO 400-300-300 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SYMJEPI 0.15 MG/0.3 ML SYRINGE |
3* |
Tier 3 |
$42.00 | $105.00 | Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMJEPI 0.3 MG/0.3 ML SYRINGE |
3* |
Tier 3 |
$42.00 | $105.00 | Q:4 /30Days |
SYMLINPEN 120 PEN INJECTOR |
5 |
Tier 5 |
27% | N/A | Q:19 /30Days |
SYMLINPEN 60 PEN INJECTOR |
5 |
Tier 5 |
27% | N/A | Q:11 /30Days |
SYMPAZAN 10 MG FILM |
5 |
Tier 5 |
27% | N/A | Q:60 /30Days |
SYMPAZAN 20 MG FILM |
5 |
Tier 5 |
27% | N/A | Q:60 /30Days |
SYMPAZAN 5 MG FILM |
5 |
Tier 5 |
27% | N/A | Q:60 /30Days |
SYMPROIC 0.2 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Tier 5 |
27% | N/A | None |
SYNDROS 5 MG/ML SOLUTION |
5 |
Tier 5 |
27% | N/A | P |
SYNJARDY 12.5-1,000 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY 12.5-500 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
4 |
Tier 4 |
$84.00 | $210.00 | Q:60 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Tier 5 |
27% | N/A | P |
SYNTHROID 100 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 112 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 125 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 150 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 175 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 200 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 25 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 300 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 50 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 75 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYNTHROID 88 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
SYPRINE 250 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | Q:240 /30Days |