2015 AR Blue Cross - Medi-Pak Advantage MA-PD (PFFS) Drug Coverage Details



Below is the Formulary, or drug list, for AR Blue Cross - Medi-Pak Advantage MA-PD (PFFS) from Usable Mutual Insurance Company This formulary is a list of prescription medications that are covered under Usable Mutual Insurance Company's 2015 Medicare Advantage Plan. The AR Blue Cross - Medi-Pak Advantage MA-PD (PFFS) plan has a $200 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $2960. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $2960 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2015 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. AR Blue Cross - Medi-Pak Advantage MA-PD (PFFS) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.





Plan Name:
AR Blue Cross - Medi-Pak Advantage MA-PD (PFFS)
Plan ID:
H4213-004
Provider: Usable Mutual Insurance Company
Plan Year:2015
Premium:$7.40
Deductible:$200
Initial Coverage Limit:$2960
Coverage Area:Arkansas






Current Table info:


Coverage level : Initial Coverage
Days Supply : 30 Days
Drugs Starting With Letter: S



Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M 
N  O  P  Q  R  S  T  U  V  W  X  Y  Z 

Coverage Level:
Pre-deductible,Initial Coverage
Coverage Gap, Catastrophic

Drug Days Pricing:
30 Day Supply, 60 Day Supply, 90 Day Supply

(Mouse over for Tips)
(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization Y/N Step Therapy Y/N Does the Deduct Apply Cost Prefered Max Cost Pref Cost Non Pref Max Cost Non Pref Cost Amt Mail Max Cost Mail
Sabril 500mg 100 Tablet, Film Coated In 1 Bottle
4
N N N N Y 30%None33%None30%None
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
4
N N N N Y 30%None33%None30%None
Samsca 15mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
N N Y N Y 25%None25%None25%None
Samsca 30mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
N N Y N Y 25%None25%None25%None
Sancuso 3.1mg/24h 1 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
4
4 28 N N Y 30%None33%None30%None
Sandimmune 100mg/mL 50 Ml In 1 Bottle
4
N N Y N Y 30%None33%None30%None
Saphris 5mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
4
60 30 N N Y 30%None33%None30%None
Saphris 10mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
4
60 30 N N Y 30%None33%None30%None
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
2
N N N N N $14None$33None$14None
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
2
N N N N N $14None$33None$14None
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
2
N N N N N $14None$33None$14None
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
5
60 30 N N Y 25%None25%None25%None
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
5
120 30 N N Y 25%None25%None25%None
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
3
N N Y N Y $40None$45None$40None
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
3
N N Y N Y $40None$45None$40None
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
3
N N Y N Y $40None$45None$40None
Serevent 50ug 60 Powder, Metered In 1 Inhaler
3
60 30 N N Y $40None$45None$40None
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
3
60 30 N N Y $40None$45None$40None
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
3
30 30 N N Y $40None$45None$40None
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
30 30 N N Y $40None$45None$40None
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
3
60 30 N N Y $40None$45None$40None
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
60 30 N N Y $40None$45None$40None
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
2
300 30 N N N $14None$33None$14None
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
30 30 N N N $3None$10None$3None
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
1
30 30 N N N $3None$10None$3None
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
60 30 N N N $3None$10None$3None
Signifor .3mg/mL 60 Package In 1 Box
5
N N Y N Y 25%None25%None25%None
Signifor .6mg/mL 60 Package In 1 Box
5
N N Y N Y 25%None25%None25%None
Signifor .9mg/mL 60 Package In 1 Box
5
N N Y N Y 25%None25%None25%None
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
2
90 30 Y N N $14None$33None$14None
Silenor 3mg 100 Tablet In 1 Bottle
3
30 30 N N Y $40None$45None$40None
Silenor 6mg 100 Tablet In 1 Bottle
3
30 30 N N Y $40None$45None$40None
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
2
N N N N N $14None$33None$14None
Simbrinza 2; 10mg/mL; mg/mL 8 Ml In 1 Bottle, Dropper
3
N N N N Y $40None$45None$40None
Simcor 500; 20mg/1; mg 90 Tablet, Film Coated, Extended Release In 1 Bottle
3
30 30 N N Y $40None$45None$40None
Simcor 750; 20mg/1; mg 90 Tablet, Film Coated, Extended Release In 1 Bottle
3
60 30 N N Y $40None$45None$40None
Simcor 1000; 20mg/1; mg 90 Tablet, Film Coated, Extended Release In 1 Bottle
3
60 30 N N Y $40None$45None$40None
Simcor 1000; 40mg/1; mg 90 Tablet, Film Coated, Extended Release In 1 Bottle
3
30 30 N N Y $40None$45None$40None
Simcor 500; 40mg/1; mg 90 Tablet, Film Coated, Extended Release In 1 Bottle
3
30 30 N N Y $40None$45None$40None
Simulect 20mg/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
5
N N Y N Y 25%None25%None25%None
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
1
45 30 N N N $3None$10None$3None
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
1
45 30 N N N $3None$10None$3None
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
60 30 N N N $3None$10None$3None
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
45 30 N N N $3None$10None$3None
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
1
30 30 N N N $3None$10None$3None
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
2
N N Y N N $14None$33None$14None
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
2
N N N N N $14None$33None$14None
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
2
N N N N N $14None$33None$14None
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
2
N N N N N $14None$33None$14None
Sodium Phenylbutyrate .94g/g 1 Bottle In 1 Carton > 250 G In 1 Bottle
5
N N N N Y 25%None25%None25%None
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
2
N N N N N $14None$33None$14None
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
4
N N N N Y 30%None33%None30%None
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
5
N N Y N Y 25%None25%None25%None
Somatuline Depot 90mg/.3mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe
5
N N Y N Y 25%None25%None25%None
Somatuline Depot 120mg/.5mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe
5
N N Y N Y 25%None25%None25%None
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N Y N Y 25%None25%None25%None
Somavert 1 Kit In 1 Package
5
N N Y N Y 25%None25%None25%None
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N Y N Y 25%None25%None25%None
Sorine 80mg 100 Blister Pack In 1 Carton
1
N N N N N $3None$10None$3None
Sorine 120mg 100 Blister Pack In 1 Carton
1
N N N N N $3None$10None$3None
Sorine 160mg 100 Blister Pack In 1 Carton
1
N N N N N $3None$10None$3None
Sorine 240mg 100 Blister Pack In 1 Carton
1
N N N N N $3None$10None$3None
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
1
N N N N N $3None$10None$3None
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
1
N N N N N $3None$10None$3None
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
2
N N N N N $14None$33None$14None
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
5
N N Y N Y 25%None25%None25%None
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
30 30 N N Y $40None$45None$40None
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N N N $14None$33None$14None
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60 30 Y N Y 25%None25%None25%None
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N N $14None$33None$14None
Ssd Cream 10g/1000g 85 G In 1 Tube
2
N N N N N $14None$33None$14None
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
2
60 30 N N N $14None$33None$14None
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
2
60 30 N N N $14None$33None$14None
Stavudine 30mg 60 Capsule In 1 Bottle
2
60 30 N N N $14None$33None$14None
Stavudine 40mg 60 Capsule In 1 Bottle
2
60 30 N N N $14None$33None$14None
Stavudine 1mg/mL 200 Ml In 1 Bottle
2
2400 30 N N N $14None$33None$14None
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
1
N N N N N $3None$10None$3None
Stimate 1.5mg/mL 1 Bottle, Spray In 1 Carton > 2.5 Ml In 1 Bottle, Spray
4
N N N N Y 30%None33%None30%None
Stivarga 40mg 3 Bottle, Plastic In 1 Box
5
84 28 Y N Y 25%None25%None25%None
Strattera 10mg 30 Capsule In 1 Bottle
4
60 30 N N Y 30%None33%None30%None
Strattera 25mg 30 Capsule In 1 Bottle
4
60 30 N N Y 30%None33%None30%None
Strattera 40mg 30 Capsule In 1 Bottle
4
60 30 N N Y 30%None33%None30%None
Strattera 18mg 30 Capsule In 1 Bottle
4
60 30 N N Y 30%None33%None30%None
Strattera 60mg 30 Capsule In 1 Bottle
4
30 30 N N Y 30%None33%None30%None
Strattera 80mg 30 Capsule In 1 Bottle
4
30 30 N N Y 30%None33%None30%None
Strattera 100mg 30 Capsule In 1 Bottle
4
30 30 N N Y 30%None33%None30%None
Streptomycin 1g 10 Vial In 1 Box
4
N N N N Y 30%None33%None30%None
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30 30 N N Y 25%None25%None25%None
Stromectol 3mg 2 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
3
N N N N Y $40None$45None$40None
Suboxone 2; .5mg/1; mg 30 Pouch In 1 Carton
4
N N Y N Y 30%None33%None30%None
Suboxone 4; 1mg/1; mg 30 Pouch In 1 Carton
4
N N Y N Y 30%None33%None30%None
Suboxone 8; 2mg/1; mg 30 Pouch In 1 Carton
4
N N Y N Y 30%None33%None30%None
Suboxone 12; 3mg/1; mg 30 Pouch In 1 Carton
4
N N Y N Y 30%None33%None30%None
Subsys .1mg 10 Blister Pack In 1 Carton > 1 Bottle, Spray In 1 Blister Pack > 1 Spray In 1 Bottle, Spray
5
120 30 Y N Y 25%None25%None25%None
Subsys .2mg 30 Blister Pack In 1 Carton > 1 Bottle, Spray In 1 Blister Pack > 1 Spray In 1 Bottle, Spray
5
120 30 Y N Y 25%None25%None25%None
Subsys .4mg 30 Blister Pack In 1 Carton > 1 Bottle, Spray In 1 Blister Pack > 1 Spray In 1 Bottle, Spray
5
120 30 Y N Y 25%None25%None25%None
Subsys .6mg 30 Blister Pack In 1 Carton > 1 Bottle, Spray In 1 Blister Pack > 1 Spray In 1 Bottle, Spray
5
120 30 Y N Y 25%None25%None25%None
Subsys .8mg 30 Blister Pack In 1 Carton > 1 Bottle, Spray In 1 Blister Pack > 1 Spray In 1 Bottle, Spray
5
120 30 Y N Y 25%None25%None25%None
Sucralfate 1g 500 Tablet In 1 Bottle
2
N N N N N $14None$33None$14None
Sulfacetamide Sodium 100mg/mL 118 Ml In 1 Bottle
2
N N N N N $14None$33None$14None
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
2
N N N N N $14None$33None$14None
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
2
N N N N N $14None$33None$14None
Sulfadiazine 500mg 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
4
N N N N Y 30%None33%None30%None
Sulfamethoxazole And Trimethoprim 200; 40mg/5mL; mg/5mL 473 Ml In 1 Bottle
2
N N N N N $14None$33None$14None
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
1
N N N N N $3None$10None$3None
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
2
N N N N N $14None$33None$14None
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
2
N N N N N $14None$33None$14None
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
1
N N N N N $3None$10None$3None
Sumatriptan 20mg/100uL 6 Container In 1 Box
4
12 30 N N Y 30%None33%None30%None
Sumatriptan 5mg/100uL 6 Container In 1 Box
4
12 30 N N Y 30%None33%None30%None
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 30 N N N $14None$33None$14None
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 30 N N N $14None$33None$14None
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
2
N N N N N $14None$33None$14None
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 30 N N N $14None$33None$14None
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
2
N N N N N $14None$33None$14None
Suprax 400mg 50 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Suprax 100mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N N N Y 30%None33%None30%None
Suprax 200mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N N N Y 30%None33%None30%None
Suprax 400mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N N N Y 30%None33%None30%None
Suprep Bowel Prep 1.6; 3.13; 17.5g/mL; g/mL; g/mL 2 Bottle, Plastic In 1 Carton > 177.4 Ml In 1 Bottle, Plastic
3
N N N N Y $40None$45None$40None
Surmontil 25mg 100 Capsule In 1 Bottle
4
N N Y N Y 30%None33%None30%None
Surmontil 50mg 100 Capsule In 1 Bottle
4
N N Y N Y 30%None33%None30%None
Surmontil 100mg 100 Capsule In 1 Bottle
4
N N Y N Y 30%None33%None30%None
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
3
90 30 N N Y $40None$45None$40None
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
3
60 30 N N Y $40None$45None$40None
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y $40None$45None$40None
Sutent 12.5mg 28 Capsule In 1 Bottle
5
90 30 Y N Y 25%None25%None25%None
Sutent 25mg 28 Capsule In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sutent 50mg 28 Capsule In 1 Bottle
5
30 30 Y N Y 25%None25%None25%None
Sylatron 1 Kit In 1 Carton
5
N N Y N Y 25%None25%None25%None
Sylatron 1 Kit In 1 Carton
5
N N Y N Y 25%None25%None25%None
Sylatron 1 Kit In 1 Carton
5
N N Y N Y 25%None25%None25%None
Sylvant 100mg 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
5
N N N N Y 25%None25%None25%None
Symbicort 160; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 120 Aerosol In 1 Canister
3
10 30 N N Y $40None$45None$40None
Symbicort 80; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 60 Aerosol In 1 Canister
3
10 30 N N Y $40None$45None$40None
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 1.5 Ml In 1 Cartridge
3
N N N N Y $40None$45None$40None
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 2.7 Ml In 1 Cartridge
3
N N N N Y $40None$45None$40None
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
5
N N N N Y 25%None25%None25%None
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
5
N N N N Y 25%None25%None25%None
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
5
N N N N Y 25%None25%None25%None
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
N N N N Y 25%None25%None25%None
Synthroid 137ug 90 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 25ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 50ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 75ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 88ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 100ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 125ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 150ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 175ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 200ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 300ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Synthroid 112ug 1000 Tablet In 1 Bottle
4
N N N N Y 30%None33%None30%None
Syprine 250mg 1 Bottle In 1 Carton > 100 Capsule In 1 Bottle
5
N N N N Y 25%None25%None25%None



Medicare Help's Additional Notes:

Coverage Levels for H4213-004

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $200. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $2960
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4700 in 2015.
4.Catastrophic: Anything over $4700 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2015 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2014
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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    Call For A licensed Sales Agent

    1-855-492-4169

  • Mon-Fri 8:30am-8:00pm
  • Sat 9:00am-3:00pm (ET)

  • Call to Enroll!