2021 Medicare Part D Plan Formulary Information |
BCN Advantage HMO-POS Prestige (HMO-POS) (H5883-003-1)
Benefit Details
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below. |
The BCN Advantage HMO-POS Prestige (HMO-POS) (H5883-003-1) Formulary Drugs Starting with the Letter S in Oceana County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $178.00 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 |
SANTYL OINTMENT |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SAPHRIS 10 MG TABLET SL BLACK CHERRY |
3 |
Preferred Brand |
$38.00 | $114.00 | S Q:180 /90Days |
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY |
3 |
Preferred Brand |
$38.00 | $114.00 | S Q:180 /90Days |
SAPHRIS 5 MG TABLET SL BLACK CHERRY |
3 |
Preferred Brand |
$38.00 | $114.00 | S Q:180 /90Days |
SAPROPTERIN 100 MG POWDER PACK [KUVAN] |
5 |
Specialty Tier |
33% | N/A | P |
SAPROPTERIN 100 MG TABLET SOL [KUVAN] |
5 |
Specialty Tier |
33% | N/A | P |
SAPROPTERIN 500 MG POWDER PACK [KUVAN] |
5 |
Specialty Tier |
33% | N/A | P |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Preferred Brand |
$38.00 | $114.00 | P Q:180 /90Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Preferred Brand |
$38.00 | $114.00 | P Q:180 /90Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Preferred Brand |
$38.00 | $114.00 | P Q:180 /90Days |
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 |
3 |
Preferred Brand |
$38.00 | $114.00 | P Q:165 /90Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Preferred Brand |
$38.00 | $114.00 | P Q:180 /90Days |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
4 |
Non-Preferred Drug |
45% | 45% | None |
SECUADO 3.8 MG/24 HR PATCH |
5 |
Specialty Tier |
33% | N/A | S Q:31 /31Days |
SECUADO 5.7 MG/24 HR PATCH |
5 |
Specialty Tier |
33% | N/A | S Q:31 /31Days |
SECUADO 7.6 MG/24 HR PATCH |
5 |
Specialty Tier |
33% | N/A | S Q:31 /31Days |
SELEGILINE HCL 5 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Generic |
$7.00 | $0.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Generic |
$7.00 | $0.00 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
SELZENTRY 20 MG/ML ORAL SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 25 MG TABLET |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft] |
2 |
Generic |
$7.00 | $0.00 | None |
SERTRALINE HCL 100 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SERTRALINE HCL 25 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
2 |
Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER 2.4 GM POWDER PACKET POWDER PACK [Renvela] |
2 |
Generic |
$7.00 | $0.00 | None |
SEVELAMER CARBONATE 800 MG TABLET [Renvela] |
2 |
Generic |
$7.00 | $0.00 | Q:1620 /90Days |
SEVELAMER HCL 400 MG TABLET [RenaGel] |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SHAROBEL 0.35 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:2 /999Days |
Signifor .6 mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
Signifor .9 mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
SIGNIFOR 0.3 MG/ML AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio] |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
SILDENAFIL 20 MG TABLET [Revatio] |
2 |
Generic |
$7.00 | $0.00 | P Q:270 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILVER SULFADIAZINE 1% CREAM |
2 |
Generic |
$7.00 | $0.00 | None |
SIMBRINZA 1%-0.2% EYE DROPS EYE DROPPER |
4 |
Non-Preferred Drug |
45% | 45% | None |
SIMVASTATIN 10 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:360 /90Days |
SIMVASTATIN 20 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:360 /90Days |
SIMVASTATIN 40 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:180 /90Days |
SIMVASTATIN 5 MG TABLET [Zocor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:360 /90Days |
SIMVASTATIN 80 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:90 /90Days |
Sirolimus 0.5 MG Tablet [Rapamune] |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
33% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
5 |
Specialty Tier |
33% | 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 |
33% | N/A | P |
SIRTURO 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
SODIUM CHLORIDE 0.45% SOLUTION IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Generic |
$7.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM CHLORIDE 3% IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM CHLORIDE INJECTION USP 5% |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl] |
5 |
Specialty Tier |
33% | N/A | None |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Specialty Tier |
33% | N/A | None |
SODIUM POLYSTYRENE SULF POWDER |
2 |
Generic |
$7.00 | $0.00 | None |
SOLIFENACIN 10 MG TABLET [VESIcare] |
3 |
Preferred Brand |
$38.00 | $114.00 | 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 |
$38.00 | $114.00 | None |
SOLTAMOX 20 MG/10 ML SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
2 |
Generic |
$7.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Generic |
$7.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2 |
Generic |
$7.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL 120 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOTALOL AF 120 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOTALOL AF 160 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $0.00 | None |
SOVALDI 150 MG PELLET PACKET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SOVALDI 200 MG PELLET PACKET |
5 |
Specialty Tier |
33% | N/A | P Q:62 /31Days |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:62 /31Days |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:12 /90Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:12 /90Days |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
SPRITAM 750 MG 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 |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:93 /31Days |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:93 /31Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:62 /31Days |
SPS 15 GM/60 ML SUSPENSION |
2 |
Generic |
$7.00 | $0.00 | None |
SSD 1% CREAM |
2 |
Generic |
$7.00 | $0.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
STELARA 45 MG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:12 /90Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SUCRALFATE 1GM TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2 |
Generic |
$7.00 | $0.00 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
2 |
Generic |
$7.00 | $0.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Generic |
$7.00 | $0.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
2 |
Generic |
$7.00 | $0.00 | None |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
2 |
Generic |
$7.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SULFASALAZINE 500 MG TABLET [Sulfazine] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SULINDAC 150 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
SULINDAC 200 MG TABLET [Clinoril] |
2 |
Generic |
$7.00 | $0.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days |
SUMATRIPTAN 4 MG/0.5 ML CART |
4 |
Non-Preferred Drug |
45% | 45% | Q:27 /90Days |
SUMATRIPTAN 4 MG/0.5 ML INJECT PEN INJCTR [Sumavel DosePro System] |
4 |
Non-Preferred Drug |
45% | 45% | Q:27 /90Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days |
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 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] |
2 |
Generic |
$7.00 | $0.00 | Q:36 /90Days |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
2 |
Generic |
$7.00 | $0.00 | Q:36 /90Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2 |
Generic |
$7.00 | $0.00 | Q:36 /90Days |
SUPREP BOWEL PREP KIT SOLUTION RECON |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:62 /31Days |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:31 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$38.00 | $114.00 | Q:31 /90Days |
SYMFI 600-300-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SYMFI LO 400-300-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SYMJEPI 0.15 MG/0.3 ML SYRINGE |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SYMJEPI 0.3 MG/0.3 ML SYRINGE |
3 |
Preferred Brand |
$38.00 | $114.00 | None |
SYMLINPEN 120 PEN INJECTOR |
5 |
Specialty Tier |
33% | N/A | P |
SYMLINPEN 60 PEN INJECTOR |
5 |
Specialty Tier |
33% | N/A | P |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
33% | N/A | P |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
33% | N/A | P |
SYMPAZAN 5 MG FILM |
4 |
Non-Preferred Drug |
45% | 45% | P |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Specialty Tier |
33% | 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 |
5 |
Specialty Tier |
33% | N/A | None |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |