2023 Medicare Part D Plan Formulary Information |
Wellcare Giveback (HMO) (H1032-204-0)
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 Wellcare Giveback (HMO) (H1032-204-0) Formulary Drugs Starting with the Letter S in St. Johns County, FL: CMS MA Region 9 which includes: FL
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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 |
SAJAZIR 30 MG/3 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:27 /30Days |
SANDIMMUNE 100MG/ML TUBEX |
4 |
Non-Preferred Drug |
48% | 48% | P |
SANTYL OINTMENT |
4 |
Non-Preferred Drug |
48% | 48% | Q:180 /30Days |
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 BOTTLE |
4 |
Non-Preferred Drug |
48% | 48% | P Q:60 /30Days |
SAVELLA TABLETS 12.5MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
48% | 48% | P Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
48% | 48% | P Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Non-Preferred Drug |
48% | 48% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TALBETS 50MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
48% | 48% | P Q:60 /30Days |
SCEMBLIX 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SCEMBLIX 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:300 /30Days |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] |
4 |
Non-Preferred Drug |
48% | 48% | P Q:10 /30Days |
SECUADO 3.8 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days |
SECUADO 5.7 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days |
SECUADO 7.6 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days |
SELEGILINE HCL 5 MG TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SELEGILINE HCL 5MG CAPSULE |
2 |
Generic |
$0.00 | $0.00 | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE |
2 |
Generic |
$0.00 | $0.00 | 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 |
4 |
Non-Preferred Drug |
48% | 48% | None |
SELZENTRY 75 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SEROQUEL 150 MG TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft Solution] |
2 |
Generic |
$0.00 | $0.00 | None |
SERTRALINE HCL 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SERTRALINE HCL 25 MG TABLET [Zoloft] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SETLAKIN 0.15 MG-0.03 MG TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SEVELAMER 0.8 GM POWDER PACKET [RENVELA] |
5 |
Specialty Tier |
33% | N/A | Q:540 /30Days |
SEVELAMER 2.4 GM POWDER PACKET POWDER PACK [Renvela] |
5 |
Specialty Tier |
33% | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SEVELAMER CARBONATE 800 MG TABLET [Renvela] |
2 |
Generic |
$0.00 | $0.00 | Q:540 /30Days |
SHAROBEL 0.35 MG TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SHINGRIX VIAL KIT |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:2 /999Days |
SIGNIFOR 0.3 MG/ML AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
SIGNIFOR 0.6 MG/ML AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
SIGNIFOR 0.9 MG/ML AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
SILDENAFIL 20 MG TABLET [Revatio] |
2 |
Generic |
$0.00 | $0.00 | P Q:360 /30Days |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
SILVER SULFADIAZINE 1% CREAM |
2 |
Generic |
$0.00 | $0.00 | None |
SIMBRINZA 1%-0.2% EYE DROP EYE DROPPER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 10 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 40 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET [Zocor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 80 MG TABLET [Zocor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
SIROLIMUS 0.5 MG TABLET [Rapamune] |
2 |
Generic |
$0.00 | $0.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
2 |
Generic |
$0.00 | $0.00 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Specialty Tier |
33% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
2 |
Generic |
$0.00 | $0.00 | P |
SIRTURO 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
SIRTURO 20 MG TABLET |
5 |
Specialty Tier |
33% | 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 |
33% | N/A | None |
SIVEXTRO 200 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
SKYRIZI 150 MG/ML PEN INJECTOR |
5 |
Specialty Tier |
33% | N/A | P Q:6 /365Days |
SKYRIZI 150 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:6 /365Days |
SKYRIZI 180 MG/1.2 ML ON-BODY WEAR INJCT |
5 |
Specialty Tier |
33% | N/A | P Q:1 /56Days |
SKYRIZI 360 MG/2.4 ML ON-BODY WEAR INJCT |
5 |
Specialty Tier |
33% | N/A | P Q:2 /56Days |
SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep] |
2 |
Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE 0.45% IV SOLUTION |
2 |
Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2 |
Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% SOLUTION PGY VL PRT |
2 |
Generic |
$0.00 | $0.00 | None |
SODIUM CHLORIDE 3% IV SOLUTION |
2 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE INJECTION USP 5% |
2 |
Generic |
$0.00 | $0.00 | None |
SODIUM OXYBATE 0.5 G/ML SOLUTION [Xyrem] |
5 |
Specialty Tier |
33% | N/A | P Q:540 /30Days |
SODIUM PHENYLBUTYRATE 500MG TABLET [Buphenyl] |
5 |
Specialty Tier |
33% | N/A | P |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
5 |
Specialty Tier |
33% | N/A | P |
SODIUM POLYSTYRENE SULF POWDER |
2 |
Generic |
$0.00 | $0.00 | None |
SOLIFENACIN 10 MG TABLET [VESIcare] |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
SOLIFENACIN 5 MG TABLET [VESIcare] |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
3 |
Preferred Brand |
$35 max* | $70.00 | Q:15 /25Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
SORAFENIB 200 MG TABLET [Nexavar] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SOTALOL 120 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SOTALOL 240 MG TABLET [Sorine] |
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 |
SOTALOL 80 MG TABLET [Sorine] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SOTALOL AF 120 MG TABLET [Sorine] |
2 |
Generic |
$0.00 | $0.00 | None |
SOTALOL AF 160 MG TABLET [Sorine] |
2 |
Generic |
$0.00 | $0.00 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
2 |
Generic |
$0.00 | $0.00 | 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 |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
2 |
Generic |
$0.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | Q:90 /30Days |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | Q:180 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | Q:120 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
SPRYCEL 20MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
SPRYCEL 50MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
SPRYCEL 70MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
SPS 15 GM/60 ML SUSPENSION |
2 |
Generic |
$0.00 | $0.00 | None |
SRONYX 0.10-0.02 MG TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SSD 1% CREAM |
2 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
STIVARGA 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2 |
Generic |
$0.00 | $0.00 | None |
STRIBILD TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SUBVENITE 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SUBVENITE 150 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SUBVENITE 200 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SUBVENITE 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SUCRALFATE 1 GM TABLET [Carafate] |
2 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] |
4 |
Non-Preferred Drug |
48% | 48% | P |
SULF-PRED 10-0.23% EYE DROPS |
2 |
Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
2 |
Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2 |
Generic |
$0.00 | $0.00 | None |
SULFACETAMIDE SOD 10% TOP SUSP |
2 |
Generic |
$0.00 | $0.00 | Q:118 /30Days |
SULFADIAZINE 500 MG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] |
2 |
Generic |
$0.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
SULFAMYLON 8.5% CREAM (G) |
4 |
Non-Preferred Drug |
48% | 48% | Q:454 /30Days |
SULFASALAZINE 500 MG TABLET [Sulfazine] |
2 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
2 |
Generic |
$0.00 | $0.00 | None |
SULINDAC 150 MG TABLET |
2 |
Generic |
$0.00 | $0.00 | None |
SULINDAC 200 MG TABLET [Clinoril] |
2 |
Generic |
$0.00 | $0.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] |
2 |
Generic |
$0.00 | $0.00 | Q:12 /30Days |
SUMATRIPTAN 4 MG/0.5 ML INJECT PEN [Sumavel DosePro System] |
2 |
Generic |
$0.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN 4 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
2 |
Generic |
$0.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN 5 MG NASAL SPRAY [Imitrex] |
2 |
Generic |
$0.00 | $0.00 | Q:24 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
2 |
Generic |
$0.00 | $0.00 | Q:6 /30Days |
SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
2 |
Generic |
$0.00 | $0.00 | Q:6 /30Days |
SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System] |
2 |
Generic |
$0.00 | $0.00 | Q:6 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] |
2 |
Generic |
$0.00 | $0.00 | Q:12 /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 |
Generic |
$0.00 | $0.00 | Q:12 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2 |
Generic |
$0.00 | $0.00 | Q:12 /30Days |
SUNITINIB MALATE 12.5 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 25 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 37.5 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 50 MG CAPSULE [Sutent] |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
SUNLENCA 4-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SUNLENCA 5-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SUPREP BOWEL PREP KIT SOLUTION RECON |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYEDA 28 TABLET [Zarah] |
2 |
Generic |
$0.00 | $0.00 | None |
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:31 /30Days |
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 |
$35.00 | $70.00 | Q:31 /30Days |
SYMDEKO 100/150 MG-150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:56 /28Days |
SYMDEKO 50/75 MG-75 MG TABLET SEQ |
5 |
Specialty Tier |
33% | N/A | P Q:56 /28Days |
SYMPAZAN 10 MG FILM |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SYMPAZAN 20 MG FILM |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SYMPAZAN 5 MG FILM |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
SYNAREL 2MG/ML NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | None |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
SYNRIBO 3.5 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
SYNTHROID 100 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 112 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 125 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
Synthroid 137ug/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 150 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 175 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 200 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 25 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 300 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 50 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 75 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |
SYNTHROID 88 MCG TABLET |
4 |
Non-Preferred Drug |
48% | 48% | None |