2024 Medicare Part D Plan Formulary Information |
Select Health Medicare Classic (HMO) (H1994-013-0)
Benefits & Contact Info
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 Select Health Medicare Classic (HMO) (H1994-013-0) Formulary Drugs Starting with the Letter S in Owyhee County, ID: CMS MA Region 23 which includes: ID
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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 |
Safyral 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
SANDIMMUNE 100MG/ML TUBEX |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
SANTYL OINTMENT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
SAPROPTERIN 100 MG POWDER PACK [KUVAN] |
5 |
Tier 5 |
30% | N/A | P |
SAPROPTERIN 100 MG TABLET SOL [KUVAN] |
5 |
Tier 5 |
30% | N/A | P |
SAPROPTERIN 500 MG POWDER PACK [KUVAN] |
5 |
Tier 5 |
30% | N/A | P |
SAVAYSA 15 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
SAVAYSA 30 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
SAVAYSA 60 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
SAVELLA TABLETS 100MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SAVELLA TABLETS 12.5MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SAVELLA TABLETS 25MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SAVELLA TALBETS 50MG 60 COUNT BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SAXAGLIPTIN HCL 2.5 MG TABLET [Onglyza] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SAXAGLIPTIN HCL 5 MG TABLET [Onglyza] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SAXAGLIPTIN-METFORMIN ER 2.5-1000 TBMP 24HR [Kombiglyze XR] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
SAXAGLIPTIN-METFORMIN ER 5-1000 TBMP 24HR [Kombiglyze XR] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SAXAGLIPTIN-METFORMIN ER 5-500 TBMP 24HR [Kombiglyze XR] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SCEMBLIX 20 MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SCEMBLIX 40 MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:300 /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] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:10 /28Days |
SECUADO 3.8 MG/24 HR PATCH |
5 |
Tier 5 |
30% | N/A | S Q:30 /30Days |
SECUADO 5.7 MG/24 HR PATCH |
5 |
Tier 5 |
30% | N/A | S Q:30 /30Days |
SECUADO 7.6 MG/24 HR PATCH |
5 |
Tier 5 |
30% | N/A | S Q:30 /30Days |
SEGLUROMET 2.5-1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SEGLUROMET 2.5-500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SEGLUROMET 7.5-1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SEGLUROMET 7.5-500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:60 /30Days |
SELEGILINE HCL 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SELEGILINE HCL 5MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SELZENTRY 20 MG/ML ORAL SOLUTION |
5 |
Tier 5 |
30% | N/A | Q:1800 /30Days |
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 |
$100.00 | $300.00 | Q:120 /30Days |
SELZENTRY 75 MG TABLET |
5 |
Tier 5 |
30% | N/A | Q:120 /30Days |
SEREVENT DIS AER 50MCG |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SEROQUEL 150 MG TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft Solution] |
2* |
Generic |
$6.00 | $0.00 | Q:300 /30Days |
SERTRALINE HCL 100 MG TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SERTRALINE HCL 25 MG TABLET [Zoloft] |
2* |
Generic |
$6.00 | $0.00 | None |
SERTRALINE HCL 50 MG TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SEVELAMER CARBONATE 800 MG TABLET [Renvela] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SEVELAMER HCL 400 MG TABLET [RenaGel] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SEVELAMER HCL 800 MG TABLET [RenaGel] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SHINGRIX VIAL KIT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SIGNIFOR 0.3 MG/ML AMPULE |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SIGNIFOR 0.6 MG/ML AMPULE |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SIGNIFOR 0.9 MG/ML AMPULE |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio] |
2* |
Generic |
$6.00 | $0.00 | P Q:180 /30Days |
SILDENAFIL 20 MG TABLET [Revatio] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days |
SILODOSIN 4 MG CAPSULE [Rapaflo] |
2* |
Generic |
$6.00 | $0.00 | Q:30 /30Days |
SILODOSIN 8 MG CAPSULE [Rapaflo] |
2* |
Generic |
$6.00 | $0.00 | Q:30 /30Days |
SILVER SULFADIAZINE 1% CREAM |
2* |
Generic |
$6.00 | $0.00 | None |
SIMBRINZA 1%-0.2% EYE DROP EYE DROPPER |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:16 /30Days |
SIMVASTATIN 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIMVASTATIN 20 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
SIMVASTATIN 40 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET [Zocor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 80 MG TABLET [Zocor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
SIROLIMUS 0.5 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
SIROLIMUS 1 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] |
5 |
Tier 5 |
30% | N/A | P |
SIROLIMUS 2 MG TABLET [Rapamune] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
SIRTURO 100 MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:188 /30Days |
SIRTURO 20 MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:1050 /30Days |
SITAVIG 50 MG BUCCAL TABLET MA |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIVEXTRO 200 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days |
SIVEXTRO 200 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days |
SLYND 4 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SODIUM CHLORIDE 0.45% IV SOLUTION |
2* |
Generic |
$6.00 | $0.00 | None |
SODIUM CHLORIDE 0.9% IRRIG. |
2* |
Generic |
$6.00 | $0.00 | P |
SODIUM CHLORIDE 0.9% SOLUTION PGY VL PRT |
2* |
Generic |
$6.00 | $0.00 | None |
SODIUM CHLORIDE 3% IV SOLUTION |
2* |
Generic |
$6.00 | $0.00 | None |
SODIUM CHLORIDE INJECTION USP 5% |
2* |
Generic |
$6.00 | $0.00 | None |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] |
2* |
Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM POLYSTYRENE SULF POWDER |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SOFOSBUVIR-VELPATASVIR 400-100 TABLET [Epclusa] |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SOHONOS 1 MG CAPSULE |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SOHONOS 1.5 MG CAPSULE |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SOHONOS 10 MG CAPSULE |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SOHONOS 2.5 MG CAPSULE |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SOHONOS 5 MG CAPSULE |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SOLIFENACIN 10 MG TABLET [VESIcare] |
2* |
Generic |
$6.00 | $0.00 | Q:30 /30Days |
SOLIFENACIN 5 MG TABLET [VESIcare] |
2* |
Generic |
$6.00 | $0.00 | Q:30 /30Days |
SOLIQUA 100 UNIT-33 MCG/ML PEN |
3 |
Preferred Brand |
$47.00 | $141.00 | S Q:18 /30Days |
SOLTAMOX 20 MG/10 ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOMAVERT 10 MG VIAL |
5 |
Tier 5 |
30% | N/A | P Q:90 /30Days |
SOMAVERT 15 MG VIAL |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SOMAVERT 20 MG VIAL |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SOMAVERT 25 MG VIAL |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SOMAVERT 30 MG VIAL |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SORAFENIB 200 MG TABLET [Nexavar] |
5 |
Tier 5 |
30% | N/A | P Q:120 /30Days |
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SOTALOL 120 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
SOTALOL 160 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL 240 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
SOTALOL 80 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
SOTALOL AF 120 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
SOTALOL AF 160 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
SOTALOL AF 80 MG TABLET [Sorine] |
2* |
Generic |
$6.00 | $0.00 | None |
SPINOSAD 0.9% TOPICAL SUSPENSION SUSPENSION [Natroba] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
SPIRIVA 18 MCG CP-HANDIHALER |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
SPIRIVA RESPIMAT 1.25 MCG INH |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SPIRIVA RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SPIRONOLACTONE 100 MG TABLET [Aldactone] |
2* |
Generic |
$6.00 | $0.00 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] |
2* |
Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPIRONOLACTONE 50 MG TABLET [Aldactone] |
2* |
Generic |
$6.00 | $0.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] |
2* |
Generic |
$6.00 | $0.00 | None |
SPRINTEC 0.25-0.035 TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SPRITAM 1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:90 /30Days |
SPRITAM 250 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:90 /30Days |
SPRITAM 500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:90 /30Days |
SPRITAM 750 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:90 /30Days |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SPRYCEL 20MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SPRYCEL 50MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SPRYCEL 70MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SPS 15 GM/60 ML SUSPENSION |
2* |
Generic |
$6.00 | $0.00 | None |
SRONYX 0.10-0.02 MG TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SSD 1% CREAM |
2* |
Generic |
$6.00 | $0.00 | None |
STEGLATRO 15 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
STEGLATRO 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
STELARA 45 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
30% | N/A | P Q:2 /84Days |
STELARA 45 MG/0.5 ML VIAL |
5 |
Tier 5 |
30% | N/A | P Q:2 /28Days |
STELARA 90 MG/ML SYRINGE |
5 |
Tier 5 |
30% | N/A | P Q:3 /84Days |
STIMUFEND 6 MG/0.6 ML SYRINGE |
5 |
Tier 5 |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
STIOLTO RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
STIVARGA 40 MG TABLET |
5 |
Tier 5 |
30% | N/A | P Q:84 /21Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL |
2* |
Generic |
$6.00 | $0.00 | P |
STRIBILD TABLET |
5 |
Tier 5 |
30% | N/A | Q:30 /30Days |
STRIVERDI RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SUCRAID 8500[iU]/mL |
5 |
Tier 5 |
30% | N/A | P Q:354 /30Days |
SUCRALFATE 1 GM TABLET [Carafate] |
2* |
Generic |
$6.00 | $0.00 | None |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SULF-PRED 10-0.23% EYE DROPS |
2* |
Generic |
$6.00 | $0.00 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] |
2* |
Generic |
$6.00 | $0.00 | None |
SULFACETAMIDE 10% EYE OINTMENT |
2* |
Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFACETAMIDE SOD 10% TOP SUSP |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SULFADIAZINE 500 MG TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] |
2* |
Generic |
$6.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] |
2* |
Generic |
$6.00 | $0.00 | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] |
2* |
Generic |
$6.00 | $0.00 | None |
SULFASALAZINE 500 MG TABLET [Sulfazine] |
2* |
Generic |
$6.00 | $0.00 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] |
2* |
Generic |
$6.00 | $0.00 | None |
SULINDAC 150 MG TABLET |
2* |
Generic |
$6.00 | $0.00 | None |
SULINDAC 200 MG TABLET [Clinoril] |
2* |
Generic |
$6.00 | $0.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] |
3 |
Preferred Brand |
$47.00 | $141.00 | S Q:12 /30Days |
SUMATRIPTAN 4 MG/0.5 ML INJECT PEN [Sumavel DosePro System] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 4 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SUMATRIPTAN 5 MG NASAL SPRAY [Imitrex] |
3 |
Preferred Brand |
$47.00 | $141.00 | S Q:12 /30Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] |
2* |
Generic |
$6.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] |
2* |
Generic |
$6.00 | $0.00 | Q:9 /30Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] |
2* |
Generic |
$6.00 | $0.00 | Q:9 /30Days |
SUNITINIB MALATE 12.5 MG CAPSULE [Sutent] |
5 |
Tier 5 |
30% | N/A | P Q:90 /30Days |
SUNITINIB MALATE 25 MG CAPSULE [Sutent] |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 37.5 MG CAPSULE [Sutent] |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUNITINIB MALATE 50 MG CAPSULE [Sutent] |
5 |
Tier 5 |
30% | N/A | P Q:30 /30Days |
SUNLENCA 4-300 MG TABLET |
5 |
Tier 5 |
30% | N/A | Q:4 /180Days |
SUNLENCA 5-300 MG TABLET |
5 |
Tier 5 |
30% | N/A | Q:5 /180Days |
SUNOSI 150 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
SUNOSI 75 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
SUPREP BOWEL PREP KIT SOLUTION RECON |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SYMLINPEN 120 PEN INJECTOR |
5 |
Tier 5 |
30% | N/A | S Q:11 /30Days |
SYMLINPEN 60 PEN INJECTOR |
5 |
Tier 5 |
30% | N/A | S Q:11 /30Days |
SYMPAZAN 10 MG FILM |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SYMPAZAN 20 MG FILM |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
SYMPAZAN 5 MG FILM |
5 |
Tier 5 |
30% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYMPROIC 0.2 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
SYMTUZA 800-150-200-10 MG TABLET |
5 |
Tier 5 |
30% | N/A | Q:30 /30Days |
SYNAREL 2MG/ML NASAL SPRAY |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
SYNJARDY 12.5-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SYNJARDY XR 25-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
SYNTHROID 100 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 112 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 125 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
Synthroid 137ug/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 150 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 175 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 200 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 25 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 300 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 50 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 75 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |
SYNTHROID 88 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days |