2015 Symphonix Rite Aid Premier Rx (PDP) Drug Coverage Details



Below is the Formulary, or drug list, for Symphonix Rite Aid Premier Rx (PDP) from Symphonix Health Insurance, Inc. This formulary is a list of prescription medications that are covered under Symphonix Health Insurance, Inc.'s 2015 Part-D Plan. The Symphonix Rite Aid Premier Rx (PDP) plan has a $0 drug deductible. 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. Symphonix Rite Aid Premier Rx (PDP) 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:
Symphonix Rite Aid Premier Rx (PDP)
Plan ID:
S0522-061
Provider: Symphonix Health Insurance, Inc.
Plan Year:2015
Premium:$94.20
Deductible:$0
Initial Coverage Limit:$2960
Coverage Area:Louisiana






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:
Initial Coverage
Coverage Gap, Catastrophic

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

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(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 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
5
N N Y N 33%None33%None33%None
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
5
N N Y N 33%None33%None33%None
Saizen 1 Kit In 1 Carton * 3 Ml In 1 Vial, Glass * 3.5 Ml In 1 Vial, Glass
5
N N Y N 33%None33%None33%None
Saizen Clickeasy 1 Kit In 1 Carton * 1.51 Ml In 1 Vial, Glass * 1.51 Ml In 1 Cartridge
5
N N Y N 33%None33%None33%None
Samsca 15mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
30 30 Y N 33%None33%None33%None
Samsca 30mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
60 30 Y N 33%None33%None33%None
Sancuso 3.1mg/24h 1 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
5
2 28 N N 33%None33%None33%None
Sandimmune 100mg/mL 50 Ml In 1 Bottle
4
N N Y N $70None$75None$70None
Sandimmune 100mg 30 Blister Pack In 1 Package
5
N N Y N 33%None33%None33%None
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
5
N N Y N 33%None33%None33%None
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
5
N N Y N 33%None33%None33%None
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
5
N N Y N 33%None33%None33%None
Saphris 5mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
3
N N N N $30None$35None$30None
Saphris 10mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
3
N N N N $30None$35None$30None
Savella 1 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
55 30 N N $30None$35None$30None
Savella 100mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $30None$35None$30None
Savella 12.5mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $30None$35None$30None
Savella 25mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $30None$35None$30None
Savella 50mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $30None$35None$30None
Seconal Sodium 100mg 100 Capsule In 1 Bottle
4
N N Y N $70None$75None$70None
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
3
N N N N $30None$35None$30None
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
2
N N N N $4None$6None$4None
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
5
N N N N 33%None33%None33%None
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
5
N N N N 33%None33%None33%None
Semprex 8; 60mg/1; mg 100 Capsule In 1 Bottle, Plastic
4
N N N N $70None$75None$70None
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
3
60 30 N N $30None$35None$30None
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
5
60 30 N N 33%None33%None33%None
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
5
120 30 N N 33%None33%None33%None
Serevent 50ug 60 Powder, Metered In 1 Inhaler
3
60 30 N N $30None$35None$30None
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
4
N N N N $70None$75None$70None
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
4
N N N N $70None$75None$70None
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
4
N N N N $70None$75None$70None
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
4
N N N N $70None$75None$70None
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
4
N N N N $70None$75None$70None
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
3
300 30 N N $30None$35None$30None
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
45 30 N N $2None$4None$2None
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
2
30 30 N N $4None$6None$4None
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
60 30 N N $2None$4None$2None
Signifor .3mg/mL 60 Package In 1 Box
5
N N Y N 33%None33%None33%None
Signifor .6mg/mL 60 Package In 1 Box
5
N N Y N 33%None33%None33%None
Signifor .9mg/mL 60 Package In 1 Box
5
N N Y N 33%None33%None33%None
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
90 30 Y N $30None$35None$30None
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
3
N N N N $30None$35None$30None
Simbrinza 2; 10mg/mL; mg/mL 8 Ml In 1 Bottle, Dropper
4
N N N N $70None$75None$70None
Simulect 20mg/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
5
N N N N 33%None33%None33%None
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
2
N N N N $4None$6None$4None
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
2
N N N N $4None$6None$4None
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
N N N N $2None$4None$2None
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
N N N N $2None$4None$2None
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
2
N N Y N $4None$6None$4None
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
4
N N Y N $70None$75None$70None
Sirturo 100mg 188 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
2
N N N N $4None$6None$4None
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
2
N N N N $4None$6None$4None
Sodium Chloride 3g/100mL 500 Ml In 1 Bag
1
N N N N $2None$4None$2None
Sodium Chloride 5g/100mL 500 Ml In 1 Bag
4
N N N N $70None$75None$70None
Sodium Chloride 2.92g/20mL 25 Vial In 1 Tray > 20 Ml In 1 Vial
4
N N N N $70None$75None$70None
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Sodium Lactate 5.6g/10mL 25 Vial, Single-dose In 1 Tray > 10 Ml In 1 Vial, Single-dose
2
N N N N $4None$6None$4None
Sodium Phenylbutyrate .94g/g 1 Bottle In 1 Carton > 250 G In 1 Bottle
5
N N N N 33%None33%None33%None
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
3
N N N N $30None$35None$30None
Solaraze 30mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
5
N N N N 33%None33%None33%None
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
4
N N N N $70None$75None$70None
Solu-cortef 250mg/2mL 1 Vial, Single-dose In 1 Carton > 2 Ml In 1 Vial, Single-dose
4
N N N N $70None$75None$70None
Solu-medrol 1 Kit In 1 Carton * 30.6 Ml In 1 Vial * 30.6 Ml In 1 Vial
3
N N N N $30None$35None$30None
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
5
N N Y N 33%None33%None33%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 33%None33%None33%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 33%None33%None33%None
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N Y N 33%None33%None33%None
Somavert 1 Kit In 1 Package
5
N N Y N 33%None33%None33%None
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N Y N 33%None33%None33%None
Sorine 80mg 100 Blister Pack In 1 Carton
2
N N N N $4None$6None$4None
Sorine 120mg 100 Blister Pack In 1 Carton
2
N N N N $4None$6None$4None
Sorine 160mg 100 Blister Pack In 1 Carton
2
N N N N $4None$6None$4None
Sorine 240mg 100 Blister Pack In 1 Carton
2
N N N N $4None$6None$4None
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
2
N N N N $4None$6None$4None
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
2
N N N N $4None$6None$4None
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
3
N N N N $30None$35None$30None
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
5
30 30 Y N 33%None33%None33%None
Spinosad 9mg/mL 1 Bottle, Plastic In 1 Carton > 120 Ml In 1 Bottle, Plastic
4
N N N N $70None$75None$70None
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
30 30 N N $30None$35None$30None
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Sporanox 10mg/mL 150 Ml In 1 Bottle
5
N N Y N 33%None33%None33%None
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N N $4None$6None$4None
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
N N Y N 33%None33%None33%None
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N $4None$6None$4None
Ssd Cream 10g/1000g 85 G In 1 Tube
2
N N N N $4None$6None$4None
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
3
N N N N $30None$35None$30None
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
3
N N N N $30None$35None$30None
Stavudine 30mg 60 Capsule In 1 Bottle
3
N N N N $30None$35None$30None
Stavudine 40mg 60 Capsule In 1 Bottle
3
N N N N $30None$35None$30None
Stavudine 1mg/mL 200 Ml In 1 Bottle
4
N N N N $70None$75None$70None
Stelara 45mg/.5mL 1 Syringe In 1 Carton > .5 Ml In 1 Syringe
5
N N Y N 33%None33%None33%None
Stelara 90mg/mL 1 Syringe In 1 Carton > 1 Ml In 1 Syringe
5
N N Y N 33%None33%None33%None
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
2
N N N N $4None$6None$4None
Stimate 1.5mg/mL 1 Bottle, Spray In 1 Carton > 2.5 Ml In 1 Bottle, Spray
4
N N N N $70None$75None$70None
Stivarga 40mg 3 Bottle, Plastic In 1 Box
5
84 28 Y N 33%None33%None33%None
Strattera 10mg 30 Capsule In 1 Bottle
4
60 30 N Y $70None$75None$70None
Strattera 25mg 30 Capsule In 1 Bottle
4
60 30 N Y $70None$75None$70None
Strattera 40mg 30 Capsule In 1 Bottle
4
60 30 N Y $70None$75None$70None
Strattera 18mg 30 Capsule In 1 Bottle
4
60 30 N Y $70None$75None$70None
Strattera 60mg 30 Capsule In 1 Bottle
4
30 30 N Y $70None$75None$70None
Strattera 80mg 30 Capsule In 1 Bottle
4
30 30 N Y $70None$75None$70None
Strattera 100mg 30 Capsule In 1 Bottle
4
30 30 N Y $70None$75None$70None
Streptomycin 1g 10 Vial In 1 Box
4
N N N N $70None$75None$70None
Striant 30mg 6 Blister Pack In 1 Box > 10 Tablet In 1 Blister Pack
4
60 30 Y N $70None$75None$70None
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
N N N N 33%None33%None33%None
Stromectol 3mg 2 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
3
N N N N $30None$35None$30None
Suboxone 2; .5mg/1; mg 30 Pouch In 1 Carton
4
90 30 N N $70None$75None$70None
Suboxone 4; 1mg/1; mg 30 Pouch In 1 Carton
4
60 30 N N $70None$75None$70None
Suboxone 8; 2mg/1; mg 30 Pouch In 1 Carton
4
90 30 N N $70None$75None$70None
Suboxone 12; 3mg/1; mg 30 Pouch In 1 Carton
4
60 30 N N $70None$75None$70None
Sucraid 8500[iU]/mL 2 Bottle In 1 Carton
5
N N N N 33%None33%None33%None
Sucralfate 1g 500 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Sulfacetamide Sodium 100mg/mL 118 Ml In 1 Bottle
3
N N N N $30None$35None$30None
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
3
N N N N $30None$35None$30None
Sulfacetamide Sodium 100mg/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
3
N N N N $30None$35None$30None
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
2
N N N N $4None$6None$4None
Sulfadiazine 500mg 1000 Tablet In 1 Bottle
4
N N N N $70None$75None$70None
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N N N $2None$4None$2None
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
4
N N N N $70None$75None$70None
Sulfamethoxazole And Trimethoprim 200; 40mg/5mL; mg/5mL 473 Ml In 1 Bottle
2
N N N N $4None$6None$4None
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
1
N N N N $2None$4None$2None
Sulfamylon 85mg/g 1 Tube In 1 Carton > 113.4 G In 1 Tube
3
N N N N $30None$35None$30None
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
3
N N N N $30None$35None$30None
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
2
N N N N $4None$6None$4None
Sumatriptan 20mg/100uL 6 Container In 1 Box
4
6 30 N N $70None$75None$70None
Sumatriptan 5mg/100uL 6 Container In 1 Box
4
6 30 N N $70None$75None$70None
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
9 30 N N $4None$6None$4None
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
9 30 N N $4None$6None$4None
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
4
4 30 N N $70None$75None$70None
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
9 30 N N $4None$6None$4None
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
4
4 30 N N $70None$75None$70None
Suprax 400mg 50 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Suprax 100mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
3
N N N N $30None$35None$30None
Suprax 200mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
3
N N N N $30None$35None$30None
Suprax 200mg/5mL 75 Ml In 1 Bottle
3
N N N N $30None$35None$30None
Suprax 500mg/5mL 20 Ml In 1 Bottle
3
N N N N $30None$35None$30None
Suprax 400mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N N N $30None$35None$30None
Suprax 100mg/5mL 50 Ml In 1 Bottle
3
N N N N $30None$35None$30None
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 $30None$35None$30None
Surmontil 25mg 100 Capsule In 1 Bottle
4
N N Y N $70None$75None$70None
Surmontil 50mg 100 Capsule In 1 Bottle
4
N N Y N $70None$75None$70None
Surmontil 100mg 100 Capsule In 1 Bottle
4
N N Y N $70None$75None$70None
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
4
N N N N $70None$75None$70None
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
4
N N N N $70None$75None$70None
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
5
N N N N 33%None33%None33%None
Sutent 12.5mg 28 Capsule In 1 Bottle
5
210 30 Y N 33%None33%None33%None
Sutent 25mg 28 Capsule In 1 Bottle
5
90 30 Y N 33%None33%None33%None
Sutent 50mg 28 Capsule In 1 Bottle
5
30 30 Y N 33%None33%None33%None
Sylatron 1 Kit In 1 Carton
5
N N Y N 33%None33%None33%None
Sylatron 1 Kit In 1 Carton
5
N N Y N 33%None33%None33%None
Sylatron 1 Kit In 1 Carton
5
N N Y N 33%None33%None33%None
Sylvant 100mg 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
5
N N Y N 33%None33%None33%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 $30None$35None$30None
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 $30None$35None$30None
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 1.5 Ml In 1 Cartridge
4
6 30 N N $70None$75None$70None
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 2.7 Ml In 1 Cartridge
5
11 30 N N 33%None33%None33%None
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
5
N N N N 33%None33%None33%None
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
5
N N Y N 33%None33%None33%None
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
5
N N N N 33%None33%None33%None
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
N N Y N 33%None33%None33%None
Synthroid 137ug 90 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 25ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 50ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 75ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 88ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 100ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 125ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 150ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 175ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 200ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 300ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Synthroid 112ug 1000 Tablet In 1 Bottle
3
N N N N $30None$35None$30None
Syprine 250mg 1 Bottle In 1 Carton > 100 Capsule In 1 Bottle
5
N N N N 33%None33%None33%None



Medicare Help's

Additional Notes:



Coverage Levels for S0522-061

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