2025 Medicare Part D Plan Formulary Information |
Cigna Healthcare Extra Rx (PDP) (S5617-266-0)
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 Cigna Healthcare Extra Rx (PDP) (S5617-266-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 21 which includes: LA
|
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 |
31% | N/A | P Q:18 /30Days |
SANCUSO 3.1 MG/24 HR PATCH  |
5 |
Specialty Tier |
31% | N/A | None |
SANTYL OINTMENT  |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days |
SAPROPTERIN 100 MG POWDER PACK [KUVAN] ![Compare how all Medicare Part D PDP plans in LA cover SAPROPTERIN 100 MG POWDER PACK [KUVAN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P |
SAPROPTERIN 100 MG TABLET SOL [KUVAN] ![Compare how all Medicare Part D PDP plans in LA cover SAPROPTERIN 100 MG TABLET SOL [KUVAN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P |
SAPROPTERIN 500 MG POWDER PACK [KUVAN] ![Compare how all Medicare Part D PDP plans in LA cover SAPROPTERIN 500 MG POWDER PACK [KUVAN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P |
SCEMBLIX 100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SCEMBLIX 20 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:600 /30Days |
SCEMBLIX 40 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:300 /30Days |
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] ![Compare how all Medicare Part D PDP plans in LA cover SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SECUADO 3.8 MG/24 HR PATCH  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SECUADO 5.7 MG/24 HR PATCH  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SECUADO 7.6 MG/24 HR PATCH  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SELEGILINE HCL 5 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | None |
SELEGILINE HCL 5MG CAPSULE  |
3 |
Preferred Brand |
18% | 18% | None |
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE  |
2* |
Generic |
$8.00 | $5.00 | None |
SELZENTRY 20 MG/ML ORAL SOLUTION  |
5 |
Specialty Tier |
31% | N/A | None |
SELZENTRY 25 MG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SELZENTRY 75 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | None |
SEREVENT DIS AER 50MCG  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
SEROQUEL 150 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SERTRALINE 20 MG/ML ORAL CONC [Zoloft Solution] ![Compare how all Medicare Part D PDP plans in LA cover SERTRALINE 20 MG/ML ORAL CONC [Zoloft Solution].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | None |
SERTRALINE HCL 100 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | Q:60 /30Days |
SERTRALINE HCL 25 MG TABLET [Zoloft] ![Compare how all Medicare Part D PDP plans in LA cover SERTRALINE HCL 25 MG TABLET [Zoloft].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | Q:60 /30Days |
SERTRALINE HCL 50 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | Q:60 /30Days |
SETLAKIN 0.15 MG-0.03 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | None |
SHAROBEL 0.35 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | None |
SHINGRIX VIAL KIT  |
3 |
Preferred Brand |
18% | 18% | Q:2 /999Days |
SIGNIFOR 0.3 MG/ML AMPULE  |
5 |
Specialty Tier |
31% | N/A | P |
SIGNIFOR 0.6 MG/ML AMPULE  |
5 |
Specialty Tier |
31% | N/A | P |
SIGNIFOR 0.9 MG/ML AMPULE  |
5 |
Specialty Tier |
31% | N/A | P |
SILDENAFIL 20 MG TABLET [Revatio] ![Compare how all Medicare Part D PDP plans in LA cover SILDENAFIL 20 MG TABLET [Revatio].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SILVER SULFADIAZINE 1% CREAM  |
3 |
Preferred Brand |
18% | 18% | None |
SIMBRINZA 1%-0.2% EYE DROP EYE DROPPER  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SIMVASTATIN 10 MG TABLET  |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 20 MG TABLET  |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 40 MG TABLET  |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 5 MG TABLET [Zocor] ![Compare how all Medicare Part D PDP plans in LA cover SIMVASTATIN 5 MG TABLET [Zocor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:30 /30Days |
SIMVASTATIN 80 MG TABLET [Zocor] ![Compare how all Medicare Part D PDP plans in LA cover SIMVASTATIN 80 MG TABLET [Zocor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:30 /30Days |
SIROLIMUS 0.5 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover SIROLIMUS 0.5 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIROLIMUS 1 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover SIROLIMUS 1 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIROLIMUS 1 MG/ML SOLUTION [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover SIROLIMUS 1 MG/ML SOLUTION [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIROLIMUS 2 MG TABLET [Rapamune] ![Compare how all Medicare Part D PDP plans in LA cover SIROLIMUS 2 MG TABLET [Rapamune].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SIRTURO 100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P |
SIRTURO 20 MG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | P |
SIVEXTRO 200 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:6 /28Days |
SIVEXTRO 200 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:6 /28Days |
SKYRIZI 150 MG/ML PEN INJECTOR  |
5 |
Specialty Tier |
31% | N/A | P Q:2 /28Days |
SKYRIZI 150 MG/ML SYRINGE  |
5 |
Specialty Tier |
31% | N/A | P Q:2 /28Days |
SKYRIZI 180 MG/1.2 ML ON-BODY WEAR INJCT  |
5 |
Specialty Tier |
31% | N/A | P Q:1.2 /56Days |
SKYRIZI 360 MG/2.4 ML ON-BODY WEAR INJCT  |
5 |
Specialty Tier |
31% | N/A | P Q:2.4 /56Days |
SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep] ![Compare how all Medicare Part D PDP plans in LA cover SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep] ![Compare how all Medicare Part D PDP plans in LA cover SOD SUL-POTASS SUL-MAG SUL SOLN RECON [Suprep].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
SODIUM CHLORIDE 0.45% IV SOLUTION  |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SODIUM CHLORIDE 0.9% IRRIG.  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM CHLORIDE 0.9% IV SOLUTION  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM CHLORIDE 3% IV SOLUTION  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM CHLORIDE INJECTION USP 5%  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SODIUM OXYBATE 0.5 G/ML SOLUTION [Xyrem] ![Compare how all Medicare Part D PDP plans in LA cover SODIUM OXYBATE 0.5 G/ML SOLUTION [Xyrem].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:540 /30Days |
SODIUM PHENYLBUTYRATE 500MG TABLET [Buphenyl] ![Compare how all Medicare Part D PDP plans in LA cover SODIUM PHENYLBUTYRATE 500MG TABLET [Buphenyl].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P |
SODIUM PHENYLBUTYRATE POWDER [Buphenyl] ![Compare how all Medicare Part D PDP plans in LA cover SODIUM PHENYLBUTYRATE POWDER [Buphenyl].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P |
SODIUM POLYSTYRENE SULF POWDER  |
3 |
Preferred Brand |
18% | 18% | None |
SOLIFENACIN 10 MG TABLET [VESIcare] ![Compare how all Medicare Part D PDP plans in LA cover SOLIFENACIN 10 MG TABLET [VESIcare].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | None |
SOLIFENACIN 5 MG TABLET [VESIcare] ![Compare how all Medicare Part D PDP plans in LA cover SOLIFENACIN 5 MG TABLET [VESIcare].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | None |
SOLIQUA 100 UNIT-33 MCG/ML PEN  |
3 |
Preferred Brand |
18% | 18% | Q:15 /24Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOLTAMOX 20 MG/10 ML SOLUTION  |
5 |
Specialty Tier |
31% | N/A | None |
SOMAVERT 10 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SOMAVERT 15 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SOMAVERT 20 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SOMAVERT 25 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SOMAVERT 30 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SORAFENIB 200 MG TABLET [Nexavar] ![Compare how all Medicare Part D PDP plans in LA cover SORAFENIB 200 MG TABLET [Nexavar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
SOTALOL 120 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 120 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SOTALOL 160 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 160 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SOTALOL 240 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 240 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SOTALOL 80 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL 80 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SOTALOL AF 120 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL AF 120 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SOTALOL AF 160 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL AF 160 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SOTALOL AF 80 MG TABLET [Sorine] ![Compare how all Medicare Part D PDP plans in LA cover SOTALOL AF 80 MG TABLET [Sorine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SOTYLIZE 5 MG/ML ORAL SOLUTION  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SPIRONOLACTONE 100 MG TABLET [Aldactone] ![Compare how all Medicare Part D PDP plans in LA cover SPIRONOLACTONE 100 MG TABLET [Aldactone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SPIRONOLACTONE 25 MG TABLET [Aldactone] ![Compare how all Medicare Part D PDP plans in LA cover SPIRONOLACTONE 25 MG TABLET [Aldactone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SPIRONOLACTONE 50 MG TABLET [Aldactone] ![Compare how all Medicare Part D PDP plans in LA cover SPIRONOLACTONE 50 MG TABLET [Aldactone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide] ![Compare how all Medicare Part D PDP plans in LA cover SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SPRINTEC 0.25-0.035 TABLET  |
3 |
Preferred Brand |
18% | 18% | None |
SPRITAM 1,000 MG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SPRITAM 250 MG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
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 |
45% | 45% | None |
SPRITAM 750 MG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SPRYCEL 20MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SPRYCEL 50MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SPRYCEL 70MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SPS 15 GM/60 ML SUSPENSION  |
3 |
Preferred Brand |
18% | 18% | None |
SRONYX 0.10-0.02 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | None |
SSD 1% CREAM  |
3 |
Preferred Brand |
18% | 18% | 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 |
31% | N/A | P Q:0.5 /28Days |
STELARA 45 MG/0.5 ML VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:0.5 /28Days |
STELARA 90 MG/ML SYRINGE  |
5 |
Specialty Tier |
31% | N/A | P Q:1 /28Days |
STIVARGA 40 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:84 /28Days |
STREPTOMYCIN FOR INJECTION 1GM/VIL  |
5 |
Specialty Tier |
31% | N/A | P |
STRIBILD TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
SUBVENITE 100 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | None |
SUBVENITE 150 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | None |
SUBVENITE 200 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | None |
SUBVENITE 25 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | None |
SUBVENITE TABLET START KIT (BLUE) TABLET DS PK  |
2* |
Generic |
$8.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUBVENITE TABLET START KIT (GREEN) TABLET DS PK  |
2* |
Generic |
$8.00 | $5.00 | None |
SUBVENITE TABLET START KIT(ORANGE) TABLET DS PK  |
2* |
Generic |
$8.00 | $5.00 | None |
SUCRAID 8500[iU]/mL ![Compare how all Medicare Part D PDP plans in LA cover SUCRAID 8500[iU]/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P |
SUCRALFATE 1 GM TABLET [Carafate] ![Compare how all Medicare Part D PDP plans in LA cover SUCRALFATE 1 GM TABLET [Carafate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate] ![Compare how all Medicare Part D PDP plans in LA cover SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | None |
SUFLAVE POWDER SOLUTION RECON  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SULF-PRED 10-0.23% EYE DROPS  |
2* |
Generic |
$8.00 | $5.00 | None |
SULFACETAMIDE 10% EYE DROPS [Sulf-10] ![Compare how all Medicare Part D PDP plans in LA cover SULFACETAMIDE 10% EYE DROPS [Sulf-10].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
SULFACETAMIDE SOD 10% TOP SUSP  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SULFADIAZINE 500 MG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS] ![Compare how all Medicare Part D PDP plans in LA cover SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric] ![Compare how all Medicare Part D PDP plans in LA cover SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | None |
SULFAMETHOXAZOLE-TMP SS TABLET [Septra] ![Compare how all Medicare Part D PDP plans in LA cover SULFAMETHOXAZOLE-TMP SS TABLET [Septra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SULFASALAZINE 500 MG TABLET [Sulfazine] ![Compare how all Medicare Part D PDP plans in LA cover SULFASALAZINE 500 MG TABLET [Sulfazine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC] ![Compare how all Medicare Part D PDP plans in LA cover SULFASALAZINE DR 500 MG TABLET [Sulfazine EC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SULINDAC 150 MG TABLET  |
2* |
Generic |
$8.00 | $5.00 | None |
SULINDAC 200 MG TABLET [Clinoril] ![Compare how all Medicare Part D PDP plans in LA cover SULINDAC 200 MG TABLET [Clinoril].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | None |
SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /28Days |
SUMATRIPTAN 4 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN 4 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | Q:8 /28Days |
SUMATRIPTAN 5 MG NASAL SPRAY [Imitrex] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN 5 MG NASAL SPRAY [Imitrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /28Days |
SUMATRIPTAN 6 MG/0.5 ML INJECT  |
4 |
Non-Preferred Drug |
45% | 45% | Q:8 /28Days |
SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
45% | 45% | Q:8 /28Days |
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN SUCC 100 MG TABLET [Imitrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | Q:18 /28Days |
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN SUCC 25 MG TABLET [Imitrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | Q:18 /28Days |
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack] ![Compare how all Medicare Part D PDP plans in LA cover SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$8.00 | $5.00 | Q:18 /28Days |
SUNITINIB MALATE 12.5 MG CAPSULE [Sutent] ![Compare how all Medicare Part D PDP plans in LA cover SUNITINIB MALATE 12.5 MG CAPSULE [Sutent].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 25 MG CAPSULE [Sutent] ![Compare how all Medicare Part D PDP plans in LA cover SUNITINIB MALATE 25 MG CAPSULE [Sutent].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 37.5 MG CAPSULE [Sutent] ![Compare how all Medicare Part D PDP plans in LA cover SUNITINIB MALATE 37.5 MG CAPSULE [Sutent].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SUNITINIB MALATE 50 MG CAPSULE [Sutent] ![Compare how all Medicare Part D PDP plans in LA cover SUNITINIB MALATE 50 MG CAPSULE [Sutent].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
SUNLENCA 4-300 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | None |
SUNLENCA 5-300 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | None |
SUTAB 1.479-0.225-0.188 GM TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYEDA 28 TABLET [Zarah] ![Compare how all Medicare Part D PDP plans in LA cover SYEDA 28 TABLET [Zarah].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
SYMPAZAN 10 MG FILM  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SYMPAZAN 20 MG FILM  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SYMPAZAN 5 MG FILM  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
SYMTUZA 800-150-200-10 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | None |
SYNAREL 2MG/ML NASAL SPRAY  |
5 |
Specialty Tier |
31% | N/A | None |
SYNJARDY 12.5-1,000 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
SYNJARDY 12.5-500 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
SYNJARDY 5-1,000 MG TABLET  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
SYNJARDY XR 10-1,000 MG TABLET BP 24H  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNJARDY XR 25-1,000 MG TABLET BP 24H  |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
SYNJARDY XR 5-1,000 MG TABLET BP 24H  |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
SYNTHROID 100 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 112 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 125 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
Synthroid 137ug/1 90 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 150 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 175 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 200 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 25 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 300 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
SYNTHROID 50 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 75 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |
SYNTHROID 88 MCG TABLET  |
4 |
Non-Preferred Drug |
45% | 45% | None |