2015 UCare for Seniors Essentials Rx (HMO-POS) Drug Coverage Details



Below is the Formulary, or drug list, for UCare for Seniors Essentials Rx (HMO-POS) from Ucare Minnesota This formulary is a list of prescription medications that are covered under Ucare Minnesota's 2015 Medicare Advantage Plan. The UCare for Seniors Essentials Rx (HMO-POS) plan has a $75 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. UCare for Seniors Essentials Rx (HMO-POS) 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:
UCare for Seniors Essentials Rx (HMO-POS)
Plan ID:
H2459-019
Provider: Ucare Minnesota
Plan Year:2015
Premium:$5.70
Deductible:$75
Initial Coverage Limit:$2960
Coverage Area:Minnesota






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
5
N N N N Y 31%None31%NoneNANone
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
5
N N N N Y 31%None31%NoneNANone
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 Y 31%None31%NoneNANone
Saphris 5mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
4
120 30 N Y Y $90None$90NoneNANone
Saphris 10mg 10 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
4
60 30 N Y Y $90None$90NoneNANone
Savella 1 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
1 30 Y N Y $45None$45NoneNANone
Savella 100mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 Y N Y $45None$45NoneNANone
Savella 12.5mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 Y N Y $45None$45NoneNANone
Savella 25mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 Y N Y $45None$45NoneNANone
Savella 50mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 Y N Y $45None$45NoneNANone
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
3
N N N N Y $45None$45NoneNANone
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
5
N N N N Y 31%None31%NoneNANone
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
5
N N N N Y 31%None31%NoneNANone
Serevent 50ug 60 Powder, Metered In 1 Inhaler
3
60 30 N N Y $45None$45NoneNANone
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
3
480 30 N Y Y $45None$45NoneNANone
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
3
161 30 N Y Y $45None$45NoneNANone
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
120 30 N Y Y $45None$45NoneNANone
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
3
81 30 N Y Y $45None$45NoneNANone
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
60 30 N Y Y $45None$45NoneNANone
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
240 30 N N Y $4None$4NoneNANone
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
1
120 30 N N Y $4None$4NoneNANone
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
60 30 N N Y $4None$4NoneNANone
Sf Rowasa 4g/60mL 28 Bottle, With Applicator In 1 Carton
4
N N N N Y $90None$90NoneNANone
Signifor .3mg/mL 60 Package In 1 Box
5
N N Y N Y 31%None31%NoneNANone
Signifor .6mg/mL 60 Package In 1 Box
5
N N Y N Y 31%None31%NoneNANone
Signifor .9mg/mL 60 Package In 1 Box
5
N N Y N Y 31%None31%NoneNANone
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
2
90 30 Y N Y $28None$28NoneNANone
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
2
N N N N Y $28None$28NoneNANone
Simponi 50mg/.5mL 1 Syringe, Glass In 1 Carton > .5 Ml In 1 Syringe, Glass
5
N N Y N Y 31%None31%NoneNANone
Simponi 100mg/mL 1 Syringe, Glass In 1 Carton > 1 Ml In 1 Syringe, Glass
5
N N Y N Y 31%None31%NoneNANone
Simponi Aria 50mg/4mL 1 Vial, Single-use In 1 Carton > 4 Ml In 1 Vial, Single-use
5
N N Y N Y 31%None31%NoneNANone
Simulect 20mg/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
4
N N Y N Y $90None$90NoneNANone
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $4None$4NoneNANone
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $4None$4NoneNANone
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $4None$4NoneNANone
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $4None$4NoneNANone
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $4None$4NoneNANone
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
2
N N Y N Y $28None$28NoneNANone
Sirturo 100mg 188 Tablet In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
2
N N N N Y $28None$28NoneNANone
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
2
N N N N Y $28None$28NoneNANone
Sodium Chloride 3g/100mL 500 Ml In 1 Bag
2
N N N N Y $28None$28NoneNANone
Sodium Chloride 5g/100mL 500 Ml In 1 Bag
2
N N N N Y $28None$28NoneNANone
Sodium Chloride 2.92g/20mL 25 Vial In 1 Tray > 20 Ml In 1 Vial
2
N N N N Y $28None$28NoneNANone
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sodium Diuril .5mg/18mL 12 Vial In 1 Carton > 18 Ml In 1 Vial
5
N N N N Y 31%None31%NoneNANone
Sodium Lactate 5.6g/10mL 25 Vial, Single-dose In 1 Tray > 10 Ml In 1 Vial, Single-dose
2
N N N N Y $28None$28NoneNANone
Sodium Phenylbutyrate .94g/g 1 Bottle In 1 Carton > 250 G In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
5
N N N N Y 31%None31%NoneNANone
Somatuline Depot 90mg/.3mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe
5
N N N N Y 31%None31%NoneNANone
Somatuline Depot 120mg/.5mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe
5
N N N N Y 31%None31%NoneNANone
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N N N Y 31%None31%NoneNANone
Somavert 1 Kit In 1 Package
5
N N N N Y 31%None31%NoneNANone
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N N N Y 31%None31%NoneNANone
Sorine 80mg 100 Blister Pack In 1 Carton
2
N N N N Y $28None$28NoneNANone
Sorine 120mg 100 Blister Pack In 1 Carton
2
N N N N Y $28None$28NoneNANone
Sorine 160mg 100 Blister Pack In 1 Carton
2
N N N N Y $28None$28NoneNANone
Sorine 240mg 100 Blister Pack In 1 Carton
2
N N N N Y $28None$28NoneNANone
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
5
N N Y N Y 31%None31%NoneNANone
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
90 30 N N Y $45None$45NoneNANone
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $4None$4NoneNANone
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $4None$4NoneNANone
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $4None$4NoneNANone
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N N N Y $4None$4NoneNANone
Sporanox 100mg 7 Pouch In 1 Dose Pack > 1 Blister Pack In 1 Pouch > 4 Capsule In 1 Blister Pack
4
120 30 N N Y $90None$90NoneNANone
Sporanox 10mg/mL 150 Ml In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N N Y $28None$28NoneNANone
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60 30 N N Y 31%None31%NoneNANone
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 N N Y 31%None31%NoneNANone
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N Y $28None$28NoneNANone
Ssd Cream 10g/1000g 85 G In 1 Tube
2
N N N N Y $28None$28NoneNANone
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Stavudine 30mg 60 Capsule In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Stavudine 40mg 60 Capsule In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Stavudine 1mg/mL 200 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Stelara 45mg/.5mL 1 Syringe In 1 Carton > .5 Ml In 1 Syringe
5
N N Y N Y 31%None31%NoneNANone
Stelara 90mg/mL 1 Syringe In 1 Carton > 1 Ml In 1 Syringe
5
N N Y N Y 31%None31%NoneNANone
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
2
N N N N Y $28None$28NoneNANone
Stivarga 40mg 3 Bottle, Plastic In 1 Box
5
84 28 Y N Y 31%None31%NoneNANone
Strattera 10mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Strattera 25mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Strattera 40mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Strattera 18mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Strattera 60mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Strattera 80mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Strattera 100mg 30 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Streptomycin 1g 10 Vial In 1 Box
3
N N N N Y $45None$45NoneNANone
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
N N N N Y 31%None31%NoneNANone
Stromectol 3mg 2 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
4
N N N N Y $90None$90NoneNANone
Suboxone 2; .5mg/1; mg 30 Pouch In 1 Carton
4
90 30 N Y Y $90None$90NoneNANone
Suboxone 4; 1mg/1; mg 30 Pouch In 1 Carton
4
90 30 N Y Y $90None$90NoneNANone
Suboxone 8; 2mg/1; mg 30 Pouch In 1 Carton
4
90 30 N Y Y $90None$90NoneNANone
Suboxone 12; 3mg/1; mg 30 Pouch In 1 Carton
4
60 30 N Y Y $90None$90NoneNANone
Sucraid 8500[iU]/mL 2 Bottle In 1 Carton
5
N N N N Y 31%None31%NoneNANone
Sucralfate 1g 500 Tablet In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sulfacetamide Sodium 100mg/mL 118 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
2
N N N N Y $28None$28NoneNANone
Sulfacetamide Sodium 100mg/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
2
N N N N Y $28None$28NoneNANone
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sulfadiazine 500mg 1000 Tablet In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
2
N N N N Y $28None$28NoneNANone
Sulfamethoxazole And Trimethoprim 200; 40mg/5mL; mg/5mL 473 Ml In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
2
N N N N Y $28None$28NoneNANone
Sulfamylon 85mg/g 1 Tube In 1 Carton > 113.4 G In 1 Tube
4
N N N N Y $90None$90NoneNANone
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
2
N N N N Y $28None$28NoneNANone
Sumatriptan 20mg/100uL 6 Container In 1 Box
2
18 28 N N Y $28None$28NoneNANone
Sumatriptan 5mg/100uL 6 Container In 1 Box
2
36 28 N N Y $28None$28NoneNANone
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 28 N N Y $28None$28NoneNANone
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 28 N N Y $28None$28NoneNANone
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
2
16 28 N N Y $28None$28NoneNANone
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 28 N N Y $28None$28NoneNANone
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
2
16 28 N N Y $28None$28NoneNANone
Suprax 400mg 50 Tablet In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Suprax 100mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N N N Y $90None$90NoneNANone
Suprax 200mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N N N Y $90None$90NoneNANone
Suprax 200mg/5mL 75 Ml In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Suprax 100mg/5mL 50 Ml In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Surmontil 25mg 100 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Surmontil 50mg 100 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Surmontil 100mg 100 Capsule In 1 Bottle
4
N N N N Y $90None$90NoneNANone
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Sutent 12.5mg 28 Capsule In 1 Bottle
5
N N N N Y 31%None31%NoneNANone
Sutent 25mg 28 Capsule In 1 Bottle
5
60 30 N N Y 31%None31%NoneNANone
Sutent 50mg 28 Capsule In 1 Bottle
5
30 30 N N Y 31%None31%NoneNANone
Sylatron 1 Kit In 1 Carton
5
N N N N Y 31%None31%NoneNANone
Sylatron 1 Kit In 1 Carton
5
N N N N Y 31%None31%NoneNANone
Sylatron 1 Kit In 1 Carton
5
N N N N Y 31%None31%NoneNANone
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 $45None$45NoneNANone
Symbicort 80; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 60 Aerosol In 1 Canister
3
7 30 N N Y $45None$45NoneNANone
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 1.5 Ml In 1 Cartridge
4
11 30 Y N Y $90None$90NoneNANone
Symlinpen 1000ug/mL 2 Cartridge In 1 Carton > 2.7 Ml In 1 Cartridge
4
19 30 Y N Y $90None$90NoneNANone
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
5
N N N N Y 31%None31%NoneNANone
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
5
N N N N Y 31%None31%NoneNANone
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
5
N N N N Y 31%None31%NoneNANone
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
N N N N Y 31%None31%NoneNANone
Synthroid 137ug 90 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 25ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 50ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 75ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 88ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 100ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 125ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 150ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 175ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 200ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 300ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Synthroid 112ug 1000 Tablet In 1 Bottle
3
N N N N Y $45None$45NoneNANone
Syprine 250mg 1 Bottle In 1 Carton > 100 Capsule In 1 Bottle
5
N N N N Y 31%None31%NoneNANone



Medicare Help's

Additional Notes:



Coverage Levels for H2459-019

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $75. 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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