2015 Cigna-HealthSpring TotalCare SMS (HMO SNP) Drug Coverage Details



Below is the Formulary, or drug list, for Cigna-HealthSpring TotalCare SMS (HMO SNP) from Healthspring Of Tennessee, Inc. This formulary is a list of prescription medications that are covered under Healthspring Of Tennessee, Inc.'s 2015 Medicare Advantage Plan. The Cigna-HealthSpring TotalCare SMS (HMO SNP) plan has a $320 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. Cigna-HealthSpring TotalCare SMS (HMO SNP) 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:
Cigna-HealthSpring TotalCare SMS (HMO SNP)
Plan ID:
H4407-004
Provider: Healthspring Of Tennessee, Inc.
Plan Year:2015
Premium:$29.30
Deductible:$320
Initial Coverage Limit:$2960
Coverage Area:Mississippi






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
1
180 30 Y N Y 15%$2.6515%$2.6515%$2.65
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
1
200 30 Y N Y 15%$2.6515%$2.6515%$2.65
Saizen 1 Kit In 1 Carton * 3 Ml In 1 Vial, Glass * 3.5 Ml In 1 Vial, Glass
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Saizen Clickeasy 1 Kit In 1 Carton * 1.51 Ml In 1 Vial, Glass * 1.51 Ml In 1 Cartridge
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Samsca 15mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Samsca 30mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
60 30 Y N Y 15%$2.6515%$2.6515%$2.65
Sandostatin Lar Depot 1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Single-use
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sandostatin Lar Depot 1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Single-use
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sandostatin Lar Depot 1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Single-use
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Saphris 5mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
60 30 N Y Y 15%$2.6515%$2.6515%$2.65
Saphris 10mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
60 30 N Y Y 15%$2.6515%$2.6515%$2.65
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
1
60 30 N N Y 15%$2.6515%$2.6515%$2.65
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
1
120 30 N N Y 15%$2.6515%$2.6515%$2.65
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
1
60 30 N N Y 15%$2.6515%$2.6515%$2.65
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
1
60 30 N N Y 15%$2.6515%$2.6515%$2.65
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
1
120 30 N N Y 15%$2.6515%$2.6515%$2.65
Serevent 50ug 60 Powder, Metered In 1 Inhaler
1
60 30 N N Y 15%$2.6515%$2.6515%$2.65
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
1
60 30 N Y Y 15%$2.6515%$2.6515%$2.65
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
1
30 30 N Y Y 15%$2.6515%$2.6515%$2.65
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
1
30 30 N Y Y 15%$2.6515%$2.6515%$2.65
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
1
60 30 N Y Y 15%$2.6515%$2.6515%$2.65
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
1
60 30 N Y Y 15%$2.6515%$2.6515%$2.65
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
1
300 30 N N Y 15%$2.6515%$2.6515%$2.65
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
1
90 30 N N Y 15%$2.6515%$2.6515%$2.65
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
60 30 N N Y 15%$2.6515%$2.6515%$2.65
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Silenor 3mg 100 Tablet In 1 Bottle
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Silenor 6mg 100 Tablet In 1 Bottle
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Simulect 20mg/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
1
90 30 N N Y 15%$2.6515%$2.6515%$2.65
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
1
90 30 N N Y 15%$2.6515%$2.6515%$2.65
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sirturo 100mg 188 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Chloride 3g/100mL 500 Ml In 1 Bag
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Chloride 5g/100mL 500 Ml In 1 Bag
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Chloride 2.92g/20mL 25 Vial In 1 Tray > 20 Ml In 1 Vial
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sodium Lactate 5.6g/10mL 25 Vial, Single-dose In 1 Tray > 10 Ml In 1 Vial, Single-dose
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sodium Phenylbutyrate .94g/g 1 Bottle In 1 Carton > 250 G In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Solu-cortef 250mg/2mL 1 Vial, Single-dose In 1 Carton > 2 Ml In 1 Vial, Single-dose
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Somatuline Depot 90mg/.3mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Somatuline Depot 120mg/.5mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Somavert 1 Kit In 1 Package
1
60 30 Y N Y 15%$2.6515%$2.6515%$2.65
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
1
60 30 Y N Y 15%$2.6515%$2.6515%$2.65
Sorine 80mg 100 Blister Pack In 1 Carton
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sorine 120mg 100 Blister Pack In 1 Carton
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sorine 160mg 100 Blister Pack In 1 Carton
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sorine 240mg 100 Blister Pack In 1 Carton
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
1
30 30 Y N Y 15%$2.6515%$2.6515%$2.65
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
1
30 30 N N Y 15%$2.6515%$2.6515%$2.65
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sporanox 10mg/mL 150 Ml In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Ssd Cream 10g/1000g 85 G In 1 Tube
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stavudine 30mg 60 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stavudine 40mg 60 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stavudine 1mg/mL 200 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stimate 1.5mg/mL 1 Bottle, Spray In 1 Carton > 2.5 Ml In 1 Bottle, Spray
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stivarga 40mg 3 Bottle, Plastic In 1 Box
1
84 21 Y N Y 15%$2.6515%$2.6515%$2.65
Strattera 10mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Strattera 25mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Strattera 40mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Strattera 18mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Strattera 60mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Strattera 80mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Strattera 100mg 30 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Streptomycin 1g 10 Vial In 1 Box
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Stromectol 3mg 2 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Suboxone 2; .5mg/1; mg 30 Pouch In 1 Carton
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Suboxone 4; 1mg/1; mg 30 Pouch In 1 Carton
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Suboxone 8; 2mg/1; mg 30 Pouch In 1 Carton
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Suboxone 12; 3mg/1; mg 30 Pouch In 1 Carton
1
90 30 Y N Y 15%$2.6515%$2.6515%$2.65
Sucralfate 1g 500 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfacetamide Sodium 100mg/mL 118 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfadiazine 500mg 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfamethoxazole And Trimethoprim 200; 40mg/5mL; mg/5mL 473 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan 20mg/100uL 6 Container In 1 Box
1
12 30 N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan 5mg/100uL 6 Container In 1 Box
1
12 30 N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
1
9 30 N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
1
9 30 N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
1
8 30 N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
1
9 30 N N Y 15%$2.6515%$2.6515%$2.65
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
1
8 30 N N Y 15%$2.6515%$2.6515%$2.65
Suprax 400mg 50 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Suprax 200mg/5mL 75 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Suprax 500mg/5mL 20 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Suprax 100mg/5mL 50 Ml In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Surmontil 25mg 100 Capsule In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Surmontil 50mg 100 Capsule In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Surmontil 100mg 100 Capsule In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Sutent 12.5mg 28 Capsule In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sutent 25mg 28 Capsule In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sutent 50mg 28 Capsule In 1 Bottle
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sylatron 1 Kit In 1 Carton
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sylatron 1 Kit In 1 Carton
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Sylatron 1 Kit In 1 Carton
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Symbicort 160; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 120 Aerosol In 1 Canister
1
11 30 N N Y 15%$2.6515%$2.6515%$2.65
Symbicort 80; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 60 Aerosol In 1 Canister
1
14 30 N N Y 15%$2.6515%$2.6515%$2.65
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 1.5 Ml In 1 Cartridge
1
6 30 Y N Y 15%$2.6515%$2.6515%$2.65
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 2.7 Ml In 1 Cartridge
1
11 30 Y N Y 15%$2.6515%$2.6515%$2.65
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
1
N N Y N Y 15%$2.6515%$2.6515%$2.65
Synthroid 137ug 90 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 25ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 50ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 75ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 88ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 100ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 125ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 150ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 175ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 200ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 300ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Synthroid 112ug 1000 Tablet In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65
Syprine 250mg 1 Bottle In 1 Carton > 100 Capsule In 1 Bottle
1
N N N N Y 15%$2.6515%$2.6515%$2.65



Medicare Help's

Additional Notes:



Coverage Levels for H4407-004

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $320. 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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