2023 Medicare Part D Plan Formulary Information |
AmeriHealth Caritas VIP Care (HMO D-SNP) (H0738-001-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The AmeriHealth Caritas VIP Care (HMO D-SNP) (H0738-001-0) Formulary Drugs Starting with the Letter S in Sussex County, DE: CMS MA Region 5 which includes: DE
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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 |
2 |
Brand |
25% | 25% | P |
SANTYL OINTMENT |
2 |
Brand |
25% | 25% | Q:90 /30Days |
SAPROPTERIN 100 MG POWDER PACK [KUVAN] |
1 |
Generic |
$6.75 | $20.25 | P |
SAPROPTERIN 100 MG TABLET SOL [KUVAN] |
1 |
Generic |
$6.75 | $20.25 | P |
SAPROPTERIN 500 MG POWDER PACK [KUVAN] |
1 |
Generic |
$6.75 | $20.25 | P |
SAVELLA TABLETS 100MG 60 COUNT BOTTLE |
2 |
Brand |
25% | 25% | S |
SAVELLA TABLETS 12.5MG 60 COUNT BOTTLE |
2 |
Brand |
25% | 25% | S |
SAVELLA TABLETS 25MG 60 COUNT BOTTLE |
2 |
Brand |
25% | 25% | S |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
2 |
Brand |
25% | 25% | S |
SAVELLA TALBETS 50MG 60 COUNT BOTTLE |
2 |
Brand |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SCEMBLIX 20 MG TABLET |
2 |
Brand |
25% | 25% | P |
SCEMBLIX 40 MG TABLET |
2 |
Brand |
25% | 25% | P |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
1 |
Generic |
$6.75 | $20.25 | None |
SECUADO 3.8 MG/24 HR PATCH |
2 |
Brand |
25% | 25% | P Q:30 /30Days |
SECUADO 5.7 MG/24 HR PATCH |
2 |
Brand |
25% | 25% | P Q:30 /30Days |
SECUADO 7.6 MG/24 HR PATCH |
2 |
Brand |
25% | 25% | P Q:30 /30Days |
SELEGILINE HCL 5 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SELEGILINE HCL 5MG CAPSULE |
1 |
Generic |
$6.75 | $20.25 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
1 |
Generic |
$6.75 | $20.25 | None |
SELZENTRY 20 MG/ML ORAL SOLUTION |
2 |
Brand |
25% | 25% | None |
SELZENTRY 25 MG TABLET |
2 |
Brand |
25% | 25% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 75 MG TABLET |
2 |
Brand |
25% | 25% | Q:60 /30Days |
SEREVENT DIS AER 50MCG |
2 |
Brand |
25% | 25% | None |
SEROQUEL 150 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | Q:60 /30Days |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
2 |
Brand |
25% | 25% | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
2 |
Brand |
25% | 25% | P |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft Solution] |
1 |
Generic |
$6.75 | $20.25 | None |
SERTRALINE HCL 100 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SERTRALINE HCL 25 MG TABLET [Zoloft] |
1 |
Generic |
$6.75 | $20.25 | None |
SERTRALINE HCL 50 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SETLAKIN 0.15 MG-0.03 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
1 |
Generic |
$6.75 | $20.25 | 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] |
1 |
Generic |
$6.75 | $20.25 | None |
SEVELAMER CARBONATE 800 MG TABLET [Renvela] |
1 |
Generic |
$6.75 | $20.25 | None |
SHAROBEL 0.35 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SHINGRIX VIAL KIT |
2 |
Brand |
25% | 25% | Q:2 /999Days |
SIGNIFOR 0.3 MG/ML AMPULE |
2 |
Brand |
25% | 25% | P |
SIGNIFOR 0.6 MG/ML AMPULE |
2 |
Brand |
25% | 25% | P |
SIGNIFOR 0.9 MG/ML AMPULE |
2 |
Brand |
25% | 25% | P |
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio] |
1 |
Generic |
$6.75 | $20.25 | P |
SILDENAFIL 20 MG TABLET [Revatio] |
1 |
Generic |
$6.75 | $20.25 | P |
SILIQ 210 MG/1.5 ML SYRINGE |
2 |
Brand |
25% | 25% | P |
SILVER SULFADIAZINE 1% CREAM |
1 |
Generic |
$6.75 | $20.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMBRINZA 1%-0.2% EYE DROP EYE DROPPER |
2 |
Brand |
25% | 25% | None |
SIMPONI 100 MG/ML PEN INJECTOR |
2 |
Brand |
25% | 25% | P |
SIMPONI 100 MG/ML SYRINGE |
2 |
Brand |
25% | 25% | P |
SIMPONI 50 MG/0.5 ML PEN INJEC |
2 |
Brand |
25% | 25% | P |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
2 |
Brand |
25% | 25% | P |
SIMVASTATIN 10 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SIMVASTATIN 20 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SIMVASTATIN 40 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SIMVASTATIN 5 MG TABLET [Zocor] |
1 |
Generic |
$6.75 | $20.25 | None |
SIMVASTATIN 80 MG TABLET [Zocor] |
1 |
Generic |
$6.75 | $20.25 | None |
SIROLIMUS 0.5 MG TABLET [Rapamune] |
1 |
Generic |
$6.75 | $20.25 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIROLIMUS 1 MG TABLET [Rapamune] |
1 |
Generic |
$6.75 | $20.25 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
1 |
Generic |
$6.75 | $20.25 | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
1 |
Generic |
$6.75 | $20.25 | P |
SIRTURO 100 MG TABLET |
2 |
Brand |
25% | 25% | P |
SIRTURO 20 MG TABLET |
2 |
Brand |
25% | 25% | P |
SKYRIZI 150 MG/ML PEN INJECTOR |
2 |
Brand |
25% | 25% | P |
SKYRIZI 150 MG/ML SYRINGE |
2 |
Brand |
25% | 25% | P |
SKYRIZI 180 MG/1.2 ML ON-BODY WEAR INJCT |
2 |
Brand |
25% | 25% | P |
SKYRIZI 360 MG/2.4 ML ON-BODY WEAR INJCT |
2 |
Brand |
25% | 25% | P |
SKYTROFA 11 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 13.3 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SKYTROFA 3 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 3.6 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 4.3 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 5.2 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 6.3 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 7.6 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SKYTROFA 9.1 MG CARTRIDGE |
2 |
Brand |
25% | 25% | P |
SODIUM CHLORIDE 0.45% IV SOLUTION |
1 |
Generic |
$6.75 | $20.25 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
1 |
Generic |
$6.75 | $20.25 | None |
SODIUM CHLORIDE 0.9% SOLUTION PGY VL PRT |
1 |
Generic |
$6.75 | $20.25 | None |
SODIUM CHLORIDE 3% IV SOLUTION |
1 |
Generic |
$6.75 | $20.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM OXYBATE 0.5 G/ML SOLUTION [Xyrem] |
1 |
Generic |
$6.75 | $20.25 | P |
SODIUM PHENYLBUTYRATE 500MG TABLET [Buphenyl] |
1 |
Generic |
$6.75 | $20.25 | P |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
1 |
Generic |
$6.75 | $20.25 | P |
SODIUM POLYSTYRENE SULF POWDER |
1 |
Generic |
$6.75 | $20.25 | None |
SOFOSBUVIR-VELPATASVIR 400-100 TABLET [Epclusa] |
2 |
Brand |
25% | 25% | P |
SOLIFENACIN 10 MG TABLET [VESIcare] |
1 |
Generic |
$6.75 | $20.25 | None |
SOLIFENACIN 5 MG TABLET [VESIcare] |
1 |
Generic |
$6.75 | $20.25 | None |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
2 |
Brand |
$35 max* | 25% | Q:30 /30Days |
SOLTAMOX 20 MG/10 ML SOLUTION |
2 |
Brand |
25% | 25% | None |
SOMAVERT 10 MG VIAL |
2 |
Brand |
25% | 25% | P |
SOMAVERT 15 MG VIAL |
2 |
Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 20 MG VIAL |
2 |
Brand |
25% | 25% | P |
SOMAVERT 25 MG VIAL |
2 |
Brand |
25% | 25% | P |
SOMAVERT 30 MG VIAL |
2 |
Brand |
25% | 25% | P |
SORAFENIB 200 MG TABLET [Nexavar] |
1 |
Generic |
$6.75 | $20.25 | P |
SOTALOL 120 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
SOTALOL 160 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
SOTALOL 240 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
SOTALOL 80 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
SOTALOL AF 120 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
SOTALOL AF 160 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
1 |
Generic |
$6.75 | $20.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTYKTU 6 MG TABLET |
2 |
Brand |
25% | 25% | P |
SPIRIVA 18 MCG CP-HANDIHALER |
2 |
Brand |
25% | 25% | None |
SPIRIVA RESPIMAT 1.25 MCG INH |
2 |
Brand |
25% | 25% | None |
SPIRIVA RESPIMAT INHAL SPRAY |
2 |
Brand |
25% | 25% | None |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
1 |
Generic |
$6.75 | $20.25 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1 |
Generic |
$6.75 | $20.25 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
1 |
Generic |
$6.75 | $20.25 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
1 |
Generic |
$6.75 | $20.25 | None |
SPRINTEC 0.25-0.035 TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SPRITAM 1,000 MG TABLET |
2 |
Brand |
25% | 25% | S Q:60 /30Days |
SPRITAM 250 MG TABLET |
2 |
Brand |
25% | 25% | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRITAM 500 MG TABLET |
2 |
Brand |
25% | 25% | S Q:60 /30Days |
SPRITAM 750 MG TABLET |
2 |
Brand |
25% | 25% | S Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
2 |
Brand |
25% | 25% | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
2 |
Brand |
25% | 25% | P |
SPRYCEL 20MG TABLET |
2 |
Brand |
25% | 25% | P |
SPRYCEL 50MG TABLET |
2 |
Brand |
25% | 25% | P |
SPRYCEL 70MG TABLET |
2 |
Brand |
25% | 25% | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
2 |
Brand |
25% | 25% | P |
SPS 15 GM/60 ML SUSPENSION |
1 |
Generic |
$6.75 | $20.25 | None |
SRONYX 0.10-0.02 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
STELARA 45 MG/0.5 ML SYRINGE |
2 |
Brand |
25% | 25% | 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 |
2 |
Brand |
25% | 25% | P |
STELARA 90 MG/ML SYRINGE |
2 |
Brand |
25% | 25% | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
2 |
Brand |
25% | 25% | P |
STIOLTO RESPIMAT INHAL SPRAY |
2 |
Brand |
25% | 25% | None |
STIVARGA 40 MG TABLET |
2 |
Brand |
25% | 25% | P |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
1 |
Generic |
$6.75 | $20.25 | None |
STRIBILD TABLET |
2 |
Brand |
25% | 25% | Q:30 /30Days |
STRIVERDI RESPIMAT INHAL SPRAY |
2 |
Brand |
25% | 25% | None |
SUCRAID 8500[iU]/mL |
2 |
Brand |
25% | 25% | P |
SUCRALFATE 1 GM TABLET [Carafate] |
1 |
Generic |
$6.75 | $20.25 | None |
SULF-PRED 10-0.23% EYE DROPS |
1 |
Generic |
$6.75 | $20.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
1 |
Generic |
$6.75 | $20.25 | None |
SULFACETAMIDE 10% EYE OINTMENT |
1 |
Generic |
$6.75 | $20.25 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
1 |
Generic |
$6.75 | $20.25 | None |
SULFADIAZINE 500 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1 |
Generic |
$6.75 | $20.25 | None |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] |
1 |
Generic |
$6.75 | $20.25 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1 |
Generic |
$6.75 | $20.25 | None |
SULFASALAZINE 500 MG TABLET [Sulfazine] |
1 |
Generic |
$6.75 | $20.25 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
1 |
Generic |
$6.75 | $20.25 | None |
SULINDAC 150 MG TABLET |
1 |
Generic |
$6.75 | $20.25 | None |
SULINDAC 200 MG TABLET [Clinoril] |
1 |
Generic |
$6.75 | $20.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] |
1 |
Generic |
$6.75 | $20.25 | Q:12 /30Days |
SUMATRIPTAN 4 MG/0.5 ML INJECT PEN [Sumavel DosePro System] |
1 |
Generic |
$6.75 | $20.25 | Q:4 /30Days |
SUMATRIPTAN 4 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
1 |
Generic |
$6.75 | $20.25 | Q:4 /30Days |
SUMATRIPTAN 5 MG NASAL SPRAY [Imitrex] |
1 |
Generic |
$6.75 | $20.25 | Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
1 |
Generic |
$6.75 | $20.25 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
1 |
Generic |
$6.75 | $20.25 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System] |
1 |
Generic |
$6.75 | $20.25 | Q:4 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] |
1 |
Generic |
$6.75 | $20.25 | Q:9 /30Days |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
1 |
Generic |
$6.75 | $20.25 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
1 |
Generic |
$6.75 | $20.25 | Q:9 /30Days |
SUNITINIB MALATE 12.5 MG CAPSULE [Sutent] |
1 |
Generic |
$6.75 | $20.25 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUNITINIB MALATE 25 MG CAPSULE [Sutent] |
1 |
Generic |
$6.75 | $20.25 | P |
SUNITINIB MALATE 37.5 MG CAPSULE [Sutent] |
1 |
Generic |
$6.75 | $20.25 | P |
SUNITINIB MALATE 50 MG CAPSULE [Sutent] |
1 |
Generic |
$6.75 | $20.25 | P |
SUNLENCA 4-300 MG TABLET |
2 |
Brand |
25% | 25% | Q:5 /365Days |
SUNLENCA 5-300 MG TABLET |
2 |
Brand |
25% | 25% | Q:5 /365Days |
SYMDEKO 100/150 MG-150 MG TABLET |
2 |
Brand |
25% | 25% | P |
SYMDEKO 50/75 MG-75 MG TABLET SEQ |
2 |
Brand |
25% | 25% | P |
SYMLINPEN 120 PEN INJECTOR |
2 |
Brand |
25% | 25% | P |
SYMLINPEN 60 PEN INJECTOR |
2 |
Brand |
25% | 25% | P |
SYMPAZAN 10 MG FILM |
2 |
Brand |
25% | 25% | S Q:60 /30Days |
SYMPAZAN 20 MG FILM |
2 |
Brand |
25% | 25% | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMPAZAN 5 MG FILM |
2 |
Brand |
25% | 25% | S Q:60 /30Days |
SYMTUZA 800-150-200-10 MG TABLET |
2 |
Brand |
25% | 25% | Q:30 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
2 |
Brand |
25% | 25% | P |
SYNDROS 5 MG/ML SOLUTION |
2 |
Brand |
25% | 25% | P |
SYNJARDY 12.5-1,000 MG TABLET |
2 |
Brand |
25% | 25% | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
2 |
Brand |
25% | 25% | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
2 |
Brand |
25% | 25% | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
2 |
Brand |
25% | 25% | Q:60 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
2 |
Brand |
25% | 25% | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
2 |
Brand |
25% | 25% | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
2 |
Brand |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNRIBO 3.5 MG/ML VIAL |
2 |
Brand |
25% | 25% | P |
SYNTHROID 100 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 112 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 125 MCG TABLET |
2 |
Brand |
25% | 25% | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
2 |
Brand |
25% | 25% | None |
SYNTHROID 150 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 175 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 200 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 25 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 300 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 50 MCG TABLET |
2 |
Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 75 MCG TABLET |
2 |
Brand |
25% | 25% | None |
SYNTHROID 88 MCG TABLET |
2 |
Brand |
25% | 25% | None |