2023 Medicare Part D Plan Formulary Information |
Kaiser Permanente Medicare Advantage High MD (HMO-POS) (H2172-002-0)
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 Kaiser Permanente Medicare Advantage High MD (HMO-POS) (H2172-002-0) Formulary Drugs Starting with the Letter S in Carroll County, MD: CMS MA Region 5 which includes: MD
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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 |
SAIZEN 5 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SAIZEN 8.8 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
SAJAZIR 30 MG/3 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN |
5 |
Specialty Tier |
33% | 33% | None |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Preferred Brand |
$42.00 | $84.00 | P |
SANTYL OINTMENT |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SAPHRIS 10 MG TABLET SL BLACK CHERRY |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SAPHRIS 5 MG TABLET SL BLACK CHERRY |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SAPROPTERIN 100 MG POWDER PACK [KUVAN] |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAPROPTERIN 100 MG TABLET SOL [KUVAN] |
5 |
Specialty Tier |
33% | 33% | None |
SAPROPTERIN 500 MG POWDER PACK [KUVAN] |
5 |
Specialty Tier |
33% | 33% | None |
SCEMBLIX 20 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SCEMBLIX 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
2 |
Generic |
$12.00 | $0.00 | None |
SECUADO 3.8 MG/24 HR PATCH |
5 |
Specialty Tier |
33% | 33% | None |
SECUADO 5.7 MG/24 HR PATCH |
5 |
Specialty Tier |
33% | 33% | None |
SECUADO 7.6 MG/24 HR PATCH |
5 |
Specialty Tier |
33% | 33% | None |
SELEGILINE HCL 5 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Generic |
$12.00 | $0.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Generic |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SELZENTRY 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SELZENTRY 25 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SELZENTRY 75 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SEROQUEL 150 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
SERTRALINE 150 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft Solution] |
2 |
Generic |
$12.00 | $0.00 | None |
SERTRALINE 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SERTRALINE HCL 100 MG TABLET |
2 |
Generic |
$12.00 | $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 [Zoloft] |
2 |
Generic |
$12.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
2 |
Generic |
$12.00 | $0.00 | None |
SEVELAMER 2.4 GM POWDER PACKET POWDER PACK [Renvela] |
2 |
Generic |
$12.00 | $0.00 | None |
SEVELAMER CARBONATE 800 MG TABLET [Renvela] |
2 |
Generic |
$12.00 | $0.00 | None |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
2 |
Generic |
$12.00 | $0.00 | None |
SEYSARA 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SEYSARA 150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SEYSARA 60 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SHINGRIX VIAL KIT |
6 |
Vaccines |
$0.00 | N/A | None |
SIGNIFOR 0.3 MG/ML AMPULE |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIGNIFOR 0.6 MG/ML AMPULE |
5 |
Specialty Tier |
33% | 33% | None |
SIGNIFOR 0.9 MG/ML AMPULE |
5 |
Specialty Tier |
33% | 33% | None |
SIKLOS 1,000 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio] |
2 |
Generic |
$12.00 | $0.00 | P |
SILDENAFIL 20 MG TABLET [Revatio] |
2 |
Generic |
$12.00 | $0.00 | P |
SILIQ 210 MG/1.5 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
2 |
Generic |
$12.00 | $0.00 | None |
SILVER SULFADIAZINE 1% CREAM |
2 |
Generic |
$12.00 | $0.00 | None |
SIMPONI 100 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SIMPONI 100 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
SIMPONI 50 MG/0.5 ML PEN INJEC |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR |
5 |
Specialty Tier |
33% | 33% | None |
SIMVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SIMVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SIMVASTATIN 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SIMVASTATIN 5 MG TABLET [Zocor] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SIMVASTATIN 80 MG TABLET [Zocor] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SIROLIMUS 0.5 MG TABLET [Rapamune] |
2 |
Generic |
$12.00 | $0.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Generic |
$12.00 | $0.00 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
33% | 33% | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
5 |
Specialty Tier |
33% | 33% | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIRTURO 20 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SIVEXTRO 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SKYCLARYS 50 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
SKYRIZI 150 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SKYRIZI 150 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYRIZI 180 MG/1.2 ML ON-BODY WEAR INJCT |
5 |
Specialty Tier |
33% | 33% | None |
SKYRIZI 360 MG/2.4 ML ON-BODY WEAR INJCT |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 11 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 13.3 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 3 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SKYTROFA 3.6 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 4.3 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 5.2 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 6.3 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 7.6 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SKYTROFA 9.1 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
SODIUM CHLORIDE 0.45% IV SOLUTION |
2 |
Generic |
$12.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Generic |
$12.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% SOLUTION PGY VL PRT |
2 |
Generic |
$12.00 | $0.00 | None |
SODIUM CHLORIDE 3% IV SOLUTION |
2 |
Generic |
$12.00 | $0.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Generic |
$12.00 | $0.00 | 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] |
5 |
Specialty Tier |
33% | 33% | P |
SODIUM PHENYLBUTYRATE 500MG TABLET [Buphenyl] |
5 |
Specialty Tier |
33% | 33% | None |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Specialty Tier |
33% | 33% | None |
SODIUM POLYSTYRENE SULF POWDER |
2 |
Generic |
$12.00 | $0.00 | None |
SOFOSBUVIR-VELPATASVIR 400-100 TABLET [Epclusa] |
5 |
Specialty Tier |
33% | 33% | P |
SOGROYA 10 MG/1.5 ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SOGROYA 15 MG/1.5 ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SOGROYA 5 MG/1.5 ML PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SOLIFENACIN 10 MG TABLET [VESIcare] |
2 |
Generic |
$12.00 | $0.00 | None |
SOLIFENACIN 5 MG TABLET [VESIcare] |
2 |
Generic |
$12.00 | $0.00 | None |
SOLTAMOX 20 MG/10 ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 10 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 15 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 20 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 25 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SOMAVERT 30 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
SORAFENIB 200 MG TABLET [Nexavar] |
5 |
Specialty Tier |
33% | 33% | None |
SOTALOL 120 MG TABLET [Sorine] |
2 |
Generic |
$12.00 | $0.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2 |
Generic |
$12.00 | $0.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
2 |
Generic |
$12.00 | $0.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2 |
Generic |
$12.00 | $0.00 | None |
SOTALOL AF 120 MG TABLET [Sorine] |
2 |
Generic |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL AF 80 MG TABLET [Sorine] |
2 |
Generic |
$12.00 | $0.00 | None |
SOTYKTU 6 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SOTYLIZE 5 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SOVALDI 150 MG PELLET PACKET |
5 |
Specialty Tier |
33% | 33% | P |
SOVALDI 200 MG PELLET PACKET |
5 |
Specialty Tier |
33% | 33% | P |
SOVALDI 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SOVALDI 400 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
2 |
Generic |
$12.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SPS 15 GM/60 ML SUSPENSION |
2 |
Generic |
$12.00 | $0.00 | None |
SSD 1% CREAM |
2 |
Generic |
$12.00 | $0.00 | None |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
STELARA 45 MG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
STELARA 90 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
Sterile Water 6mg/mL 1 INJECTION, SOLUTION per CARTON |
5 |
Specialty Tier |
33% | 33% | P |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
5 |
Specialty Tier |
33% | 33% | None |
STRIBILD TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SUBVENITE 100 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SUBVENITE 150 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SUBVENITE 200 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SUBVENITE 25 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SUBVENITE TABLET START KIT (BLUE) TABLET DS PK |
2 |
Generic |
$12.00 | $0.00 | None |
SUBVENITE TABLET START KIT (GREEN) TABLET DS PK |
2 |
Generic |
$12.00 | $0.00 | None |
SUBVENITE TABLET START KIT(ORANGE) TABLET DS PK |
2 |
Generic |
$12.00 | $0.00 | None |
SUCRAID 8500[iU]/mL |
5 |
Specialty Tier |
33% | 33% | None |
SUCRALFATE 1 GM TABLET [Carafate] |
2 |
Generic |
$12.00 | $0.00 | None |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] |
2 |
Generic |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULF-PRED 10-0.23% EYE DROPS |
2 |
Generic |
$12.00 | $0.00 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
2 |
Generic |
$12.00 | $0.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
2 |
Generic |
$12.00 | $0.00 | None |
SULFADIAZINE 500 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
2 |
Generic |
$12.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] |
2 |
Generic |
$12.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
2 |
Generic |
$12.00 | $0.00 | None |
SULFAMYLON 8.5% CREAM (G) |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SULFASALAZINE 500 MG TABLET [Sulfazine] |
2 |
Generic |
$12.00 | $0.00 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
2 |
Generic |
$12.00 | $0.00 | None |
SULINDAC 150 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULINDAC 200 MG TABLET [Clinoril] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN 5 MG NASAL SPRAY [Imitrex] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
2 |
Generic |
$12.00 | $0.00 | None |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2 |
Generic |
$12.00 | $0.00 | None |
SUNITINIB MALATE 12.5 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | 33% | None |
SUNITINIB MALATE 25 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUNITINIB MALATE 37.5 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | 33% | None |
SUNITINIB MALATE 50 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | 33% | None |
SUNLENCA 4-300 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SUNLENCA 5-300 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
SUTENT 12.5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
SUTENT 25mg/1 28 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
SUTENT 37.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
SUTENT 50MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
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 |
$42.00 | $84.00 | None |
SYMDEKO 100/150 MG-150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
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 |
5 |
Specialty Tier |
33% | 33% | None |
SYMFI 600-300-300 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SYMFI LO 400-300-300 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
SYMLINPEN 120 PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SYMLINPEN 60 PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
33% | 33% | None |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
33% | 33% | None |
SYMPAZAN 5 MG FILM |
5 |
Specialty Tier |
33% | 33% | None |
SYMTUZA 800-150-200-10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | None |
SYNDROS 5 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |