2021 Medicare Part D Plan Formulary Information |
Elixir RxPlus (PDP) (S7694-011-0)
Benefit Details
|
The Elixir RxPlus (PDP) (S7694-011-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $61.90 Deductible: $445 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 |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Drug |
28% | 28% | P |
SANTYL OINTMENT |
4 |
Non-Preferred Drug |
28% | 28% | None |
SAPROPTERIN 100 MG POWDER PACK [KUVAN] |
5 |
Specialty Tier |
25% | N/A | P |
SAPROPTERIN 100 MG TABLET SOL [KUVAN] |
5 |
Specialty Tier |
25% | N/A | P |
SAPROPTERIN 500 MG POWDER PACK [KUVAN] |
5 |
Specialty Tier |
25% | N/A | P |
SAVELLA TABLETS 100MG 60 COUNT BOT |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOT |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOT |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
3 |
Preferred Brand |
15% | 15% | Q:110 /365Days |
SAVELLA TALBETS 50MG 60 COUNT BOT |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SECUADO 3.8 MG/24 HR PATCH |
5 |
Specialty Tier |
25% | N/A | None |
SECUADO 5.7 MG/24 HR PATCH |
5 |
Specialty Tier |
25% | N/A | None |
SECUADO 7.6 MG/24 HR PATCH |
5 |
Specialty Tier |
25% | N/A | None |
SELEGILINE HCL 5 MG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SELEGILINE HCL 5MG CAPSULE |
3 |
Preferred Brand |
15% | 15% | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Generic |
$7.00 | $10.50 | None |
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | Q:240 /30Days |
SELZENTRY 20 MG/ML ORAL SOLUTION |
5 |
Specialty Tier |
25% | N/A | Q:1800 /30Days |
SELZENTRY 25 MG TABLET |
3 |
Preferred Brand |
15% | 15% | Q:120 /30Days |
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SERTRALINE HCL 100 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SERTRALINE HCL 25 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SETLAKIN 0.15 MG-0.03 MG TAB |
4 |
Non-Preferred Drug |
28% | 28% | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SEVELAMER 2.4 GM POWDER PACKET POWDER PACK [Renvela] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SEVELAMER CARBONATE 800 MG TABLET [Renvela] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SEVELAMER HCL 400 MG TABLET [RenaGel] |
4 |
Non-Preferred Drug |
28% | 28% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SHAROBEL 0.35 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | None |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
15% | 15% | None |
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 |
SIGNIFOR 0.3 MG/ML AMPULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SILDENAFIL 20 MG TABLET [Revatio] |
3 |
Preferred Brand |
15% | 15% | P Q:90 /30Days |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SILVER SULFADIAZINE 1% CREAM |
2 |
Generic |
$7.00 | $10.50 | None |
SIMBRINZA 1%-0.2% EYE DROPS EYE DROPPER |
4 |
Non-Preferred Drug |
28% | 28% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SIMVASTATIN 40 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SIMVASTATIN 5 MG TABLET [Zocor] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SIMVASTATIN 80 MG TABLET |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Sirolimus 0.5 MG Tablet [Rapamune] |
4 |
Non-Preferred Drug |
28% | 28% | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
28% | 28% | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
25% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
28% | 28% | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
SIRTURO 20 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT |
5 |
Specialty Tier |
25% | N/A | P Q:6 /365Days |
SODIUM CHLORIDE 0.45% SOLUTION IV SOLUTION |
4 |
Non-Preferred Drug |
28% | 28% | P |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Generic |
$7.00 | $10.50 | None |
SODIUM CHLORIDE 0.9% IV SOLUTION |
4 |
Non-Preferred Drug |
28% | 28% | P |
SODIUM CHLORIDE 3% IV SOLUTION |
4 |
Non-Preferred Drug |
28% | 28% | P |
SODIUM CHLORIDE INJECTION USP 5% |
4 |
Non-Preferred Drug |
28% | 28% | 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 |
4 |
Non-Preferred Drug |
28% | 28% | 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 |
Preferred Brand |
15% | 15% | Q:18 /28Days |
SOLTAMOX 20 MG/10 ML SOLUTION |
4 |
Non-Preferred Drug |
28% | 28% | P |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:60 /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 |
$7.00 | $10.50 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
2 |
Generic |
$7.00 | $10.50 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
2 |
Generic |
$7.00 | $10.50 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
2 |
Generic |
$7.00 | $10.50 | 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 | $10.50 | None |
SOTALOL 160 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $10.50 | None |
SOTALOL 240 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $10.50 | None |
SOTALOL 80 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $10.50 | None |
SOTALOL AF 120 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $10.50 | None |
SOTALOL AF 160 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $10.50 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
2 |
Generic |
$7.00 | $10.50 | None |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
15% | 15% | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
15% | 15% | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
15% | 15% | Q:4 /30Days |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
2 |
Generic |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
2 |
Generic |
$7.00 | $10.50 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
2 |
Generic |
$7.00 | $10.50 | None |
SPRINTEC 0.25-0.035 TABLET |
4 |
Non-Preferred Drug |
28% | 28% | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | Q:90 /30Days |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | Q:120 /30Days |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | Q:120 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /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:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
SPS 15 GM/60 ML SUSPENSION |
4 |
Non-Preferred Drug |
28% | 28% | None |
SRONYX 0.10-0.02 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | None |
SSD 1% CREAM |
2 |
Generic |
$7.00 | $10.50 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
STELARA 45 MG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
STRIBILD 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 |
SUBOXONE 12 MG-3 MG SL FILM |
4 |
Non-Preferred Drug |
28% | 28% | None |
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Drug |
28% | 28% | None |
SUBOXONE 4 MG-1 MG SL FILM |
4 |
Non-Preferred Drug |
28% | 28% | None |
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH |
4 |
Non-Preferred Drug |
28% | 28% | None |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
25% | N/A | None |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SUCRALFATE 1GM TABLET |
2 |
Generic |
$7.00 | $10.50 | None |
SULF-PRED 10-0.23% EYE DROPS |
2 |
Generic |
$7.00 | $10.50 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
2 |
Generic |
$7.00 | $10.50 | None |
SULFACETAMIDE 10% EYE OINTMENT |
4 |
Non-Preferred Drug |
28% | 28% | None |
SULFACETAMIDE SOD 10% TOP SUSP |
4 |
Non-Preferred Drug |
28% | 28% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Sulfadiazine 500mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
28% | 28% | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
2 |
Generic |
$7.00 | $10.50 | None |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
2 |
Generic |
$7.00 | $10.50 | None |
SULFASALAZINE 500 MG TABLET [Sulfazine] |
2 |
Generic |
$7.00 | $10.50 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
2 |
Generic |
$7.00 | $10.50 | None |
SULINDAC 150 MG TABLET |
2 |
Generic |
$7.00 | $10.50 | None |
SULINDAC 200 MG TABLET [Clinoril] |
2 |
Generic |
$7.00 | $10.50 | None |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] |
4 |
Non-Preferred Drug |
28% | 28% | Q:18 /30Days |
Sumatriptan 5 MG/ACTUAT Nasal Spray |
4 |
Non-Preferred Drug |
28% | 28% | Q:18 /30Days |
Sumatriptan 6 mg/0.5 ml vial |
4 |
Non-Preferred Drug |
28% | 28% | Q:8 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] |
2 |
Generic |
$7.00 | $10.50 | Q:9 /30Days |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
2 |
Generic |
$7.00 | $10.50 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2 |
Generic |
$7.00 | $10.50 | Q:9 /30Days |
SUNOSI 150 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | P Q:30 /30Days |
SUNOSI 75 MG TABLET |
4 |
Non-Preferred Drug |
28% | 28% | P Q:30 /30Days |
SUPREP BOWEL PREP KIT SOLUTION RECON |
4 |
Non-Preferred Drug |
28% | 28% | None |
SUTAB 1.479-0.225-0.188 GM TABLET |
4 |
Non-Preferred Drug |
28% | 28% | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYEDA 28 TABLET [Zarah] |
4 |
Non-Preferred Drug |
28% | 28% | None |
SYMDEKO 100/150 MG-150 MG TABS |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
SYMDEKO 50/75 MG-75 MG TABLET SEQ |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
SYMPAZAN 5 MG FILM |
4 |
Non-Preferred Drug |
28% | 28% | 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 |
SYNDROS 5 MG/ML SOLUTION |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
15% | 15% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
15% | 15% | Q:30 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
15% | 15% | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
15% | 15% | Q:60 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
SYNTHROID 100 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 112 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 125 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 150 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 175 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 200 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 25 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 300 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 50 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 75 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |
SYNTHROID 88 MCG TABLET |
3 |
Preferred Brand |
15% | 15% | None |