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 Preferred |
Max |
Cost Non Preferred |
Max |
Cost Mail |
Max |
Sabril |
500mg |
100 Tablet, Film Coated In 1 Bottle |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sabril |
50mg/mL |
50 Packet In 1 Carton > 10 Ml In 1 Packet |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Samsca |
15mg |
1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Samsca |
30mg |
1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sandimmune |
100mg/mL |
50 Ml In 1 Bottle |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Selegiline Hydrochloride |
5mg |
60 Capsule In 1 Bottle |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Selegiline Hydrochloride |
5mg |
500 Tablet In 1 Bottle |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Selenium Sulfide |
2.5mg/100mL |
118 Ml In 1 Bottle |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Selzentry |
150mg |
60 Tablet, Film Coated In 1 Bottle |
5 |
60 |
30 |
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Selzentry |
300mg |
60 Tablet, Film Coated In 1 Bottle |
5 |
120 |
30 |
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sensipar |
30mg |
30 Tablet, Coated In 1 Bottle, Plastic |
3 |
|
|
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Sensipar |
60mg |
30 Tablet, Coated In 1 Bottle, Plastic |
3 |
|
|
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Sensipar |
90mg |
30 Tablet, Coated In 1 Bottle, Plastic |
3 |
|
|
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Serevent |
50ug |
60 Powder, Metered In 1 Inhaler |
3 |
60 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Seroquel |
50mg |
100 Tablet, Extended Release In 1 Box, Unit-dose |
3 |
60 |
30 |
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Seroquel |
150mg |
100 Tablet, Extended Release In 1 Dose Pack |
3 |
30 |
30 |
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Seroquel |
200mg |
10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack |
3 |
30 |
30 |
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Seroquel |
300mg |
60 Tablet, Extended Release In 1 Bottle |
3 |
60 |
30 |
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Seroquel |
400mg |
10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack |
3 |
60 |
30 |
Y |
N |
Y |
$47 | N | $47 | N | $47 | N |
Sertraline Hydrochloride |
20mg/mL |
1 Bottle In 1 Carton > 60 Ml In 1 Bottle |
2 |
300 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sertraline Hydrochloride |
25mg |
30 Tablet In 1 Bottle |
1 |
30 |
30 |
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sertraline Hydrochloride |
50mg |
30 Tablet In 1 Bottle |
1 |
30 |
30 |
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sertraline Hydrochloride |
100mg |
30 Tablet In 1 Bottle |
1 |
60 |
30 |
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Signifor |
.3mg/mL |
60 Package In 1 Box |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Signifor |
.6mg/mL |
60 Package In 1 Box |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Signifor |
.9mg/mL |
60 Package In 1 Box |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sildenafil |
20mg |
90 Tablet, Film Coated In 1 Bottle, Plastic |
2 |
90 |
30 |
Y |
N |
N |
$20 | N | $20 | N | $20 | N |
Silenor |
3mg |
100 Tablet In 1 Bottle |
3 |
30 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Silenor |
6mg |
100 Tablet In 1 Bottle |
3 |
30 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Silver Sulfadiazene |
10g/1000g |
50 G In 1 Jar |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Simbrinza |
2; 10mg/mL; mg/mL |
8 Ml In 1 Bottle, Dropper |
3 |
|
|
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Simcor |
500; 20mg/1; mg |
90 Tablet, Film Coated, Extended Release In 1 Bottle |
3 |
30 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Simcor |
750; 20mg/1; mg |
90 Tablet, Film Coated, Extended Release In 1 Bottle |
3 |
60 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Simcor |
1000; 20mg/1; mg |
90 Tablet, Film Coated, Extended Release In 1 Bottle |
3 |
60 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Simcor |
1000; 40mg/1; mg |
90 Tablet, Film Coated, Extended Release In 1 Bottle |
3 |
30 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Simcor |
500; 40mg/1; mg |
90 Tablet, Film Coated, Extended Release In 1 Bottle |
3 |
30 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Simulect |
20mg/5mL |
1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Simvastatin |
10mg |
30 Tablet, Film Coated In 1 Bottle |
6 |
45 |
30 |
N |
N |
N |
$2 | N | $2 | N | $2 | N |
Simvastatin |
5mg |
90 Tablet, Film Coated In 1 Bottle |
6 |
45 |
30 |
N |
N |
N |
$2 | N | $2 | N | $2 | N |
Simvastatin |
20mg |
500 Tablet, Film Coated In 1 Bottle |
6 |
60 |
30 |
N |
N |
N |
$2 | N | $2 | N | $2 | N |
Simvastatin |
40mg |
500 Tablet, Film Coated In 1 Bottle |
6 |
45 |
30 |
N |
N |
N |
$2 | N | $2 | N | $2 | N |
Simvastatin |
80mg |
1000 Tablet, Film Coated In 1 Bottle |
6 |
30 |
30 |
N |
N |
N |
$2 | N | $2 | N | $2 | N |
Sirolimus |
.5mg |
100 Tablet, Film Coated In 1 Bottle |
2 |
|
|
Y |
N |
N |
$20 | N | $20 | N | $20 | N |
Sirturo |
100mg |
188 Tablet In 1 Bottle |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sivextro |
200mg |
10 Vial, Glass In 1 Carton > 1 Powder, For Solution In 1 Vial, Glass |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sivextro |
200mg |
30 Tablet, Coated In 1 Bottle |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sodium Chloride |
4.5g/1000mL |
1000 Ml In 1 Bag |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sodium Chloride |
9g/1000mL |
4 Bag In 1 Package > 100 Ml In 1 Bag |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sodium Chloride |
900mg/100mL |
9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sodium Phenylbutyrate |
.94g/g |
1 Bottle In 1 Carton > 250 G In 1 Bottle |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sodium Polystyrene Sulfonate |
15g/60mL |
473 Ml In 1 Bottle |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Soltamox |
10mg/5mL |
1 Bottle In 1 Carton > 150 Ml In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Somatuline Depot |
60mg/.2mL |
1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Somatuline Depot |
90mg/.3mL |
1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Somatuline Depot |
120mg/.5mL |
1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Somavert |
|
1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Somavert |
|
1 Kit In 1 Package |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Somavert |
|
1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sorine |
80mg |
100 Blister Pack In 1 Carton |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sorine |
120mg |
100 Blister Pack In 1 Carton |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sorine |
160mg |
100 Blister Pack In 1 Carton |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sorine |
240mg |
100 Blister Pack In 1 Carton |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sotalol Hydrochloride |
240mg |
100 Tablet In 1 Bottle |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sotalol Hydrochloride |
160mg |
100 Tablet In 1 Bottle |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sotalol Hydrochloride |
120mg |
100 Tablet In 1 Bottle, Plastic |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sotalol Hydrochloride |
80mg |
100 Tablet In 1 Bottle, Plastic |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sovaldi |
400mg |
28 Tablet, Film Coated In 1 Bottle |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Spiriva |
18ug |
9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack |
3 |
30 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Spironolactone |
100mg |
100 Tablet, Film Coated In 1 Bottle, Plastic |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Spironolactone |
25mg |
100 Tablet, Film Coated In 1 Bottle, Plastic |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Spironolactone |
50mg |
100 Tablet, Film Coated In 1 Bottle, Plastic |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Spironolactone And Hydrochlorothiazide |
25; 25mg/1; mg |
500 Tablet In 1 Bottle, Plastic |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sprintec |
|
6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sprycel |
70mg |
1 Bottle In 1 Carton > 60 Tablet In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sprycel |
20mg |
1 Bottle In 1 Carton > 60 Tablet In 1 Bottle |
5 |
60 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sprycel |
50mg |
1 Bottle In 1 Carton > 60 Tablet In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sprycel |
100mg |
1 Bottle In 1 Carton > 30 Tablet In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sprycel |
80mg |
1 Bottle In 1 Carton > 30 Tablet In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sprycel |
140mg |
1 Bottle In 1 Carton > 30 Tablet In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sronyx |
|
6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Ssd Cream |
10g/1000g |
85 G In 1 Tube |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Stavudine |
15mg |
60 Capsule In 1 Bottle, Plastic |
2 |
60 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Stavudine |
20mg |
60 Capsule In 1 Bottle, Plastic |
2 |
60 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Stavudine |
30mg |
60 Capsule In 1 Bottle |
2 |
60 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Stavudine |
40mg |
60 Capsule In 1 Bottle |
2 |
60 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Stelara |
45mg/.5mL |
1 Syringe In 1 Carton > .5 Ml In 1 Syringe |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Stelara |
90mg/mL |
1 Syringe In 1 Carton > 1 Ml In 1 Syringe |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sterile Water |
1mL/mL |
16 Container In 1 Case > 1000 Ml In 1 Container |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Stimate |
1.5mg/mL |
1 Bottle, Spray In 1 Carton > 2.5 Ml In 1 Bottle, Spray |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Stivarga |
40mg |
3 Bottle, Plastic In 1 Box |
5 |
84 |
28 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Strattera |
10mg |
30 Capsule In 1 Bottle |
4 |
60 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Strattera |
25mg |
30 Capsule In 1 Bottle |
4 |
60 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Strattera |
40mg |
30 Capsule In 1 Bottle |
4 |
60 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Strattera |
18mg |
30 Capsule In 1 Bottle |
4 |
60 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Strattera |
60mg |
30 Capsule In 1 Bottle |
4 |
30 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Strattera |
80mg |
30 Capsule In 1 Bottle |
4 |
30 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Strattera |
100mg |
30 Capsule In 1 Bottle |
4 |
30 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Streptomycin |
1g |
10 Vial In 1 Box |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
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% | N | 25% | N | 25% | N |
Suboxone |
2; .5mg/1; mg |
30 Pouch In 1 Carton |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Suboxone |
4; 1mg/1; mg |
30 Pouch In 1 Carton |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Suboxone |
8; 2mg/1; mg |
30 Pouch In 1 Carton |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Suboxone |
12; 3mg/1; mg |
30 Pouch In 1 Carton |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Sucralfate |
1g |
500 Tablet In 1 Bottle |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulfacetamide Sodium |
100mg/mL |
118 Ml In 1 Bottle |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulfacetamide Sodium |
100mg/mL |
1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulfacetamide Sodium And Prednisolone Sodium Phosp |
2.5; 100mg/mL; mg/mL |
10 Ml In 1 Bottle |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulfamethoxazole And Trimethoprim |
400; 80mg/1; mg |
500 Tablet In 1 Bottle, Plastic |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sulfamethoxazole And Trimethoprim |
80; 16mg/mL; mg/mL |
10 Vial, Multi-dose In 1 Carton |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Sulfamethoxazole And Trimethoprim |
800; 160mg/1; mg |
100 Tablet In 1 Bottle |
1 |
|
|
N |
N |
N |
$4 | N | $4 | N | $4 | N |
Sulfasalazine |
500mg |
500 Tablet In 1 Bottle, Plastic |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulfasalazine |
500mg |
300 Tablet, Delayed Release In 1 Bottle, Plastic |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulindac |
150mg |
100 Tablet In 1 Bottle, Plastic |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sulindac |
200mg |
500 Tablet In 1 Bottle, Plastic |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sumatriptan |
20mg/100uL |
6 Container In 1 Box |
4 |
12 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Sumatriptan |
5mg/100uL |
6 Container In 1 Box |
4 |
12 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Sumatriptan |
100mg |
1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack |
2 |
18 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sumatriptan |
50mg |
1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack |
2 |
18 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sumatriptan Succinate |
6mg/.5mL |
2 Syringe In 1 Package > .5 Ml In 1 Syringe |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sumatriptan Succinate |
25mg |
9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack |
2 |
18 |
30 |
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Sumatriptan Succinate |
6mg/.5mL |
1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose |
2 |
|
|
N |
N |
N |
$20 | N | $20 | N | $20 | N |
Suprax |
100mg |
1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Suprax |
200mg |
1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Suprax |
400mg |
1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
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 |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Surmontil |
25mg |
100 Capsule In 1 Bottle |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Surmontil |
50mg |
100 Capsule In 1 Bottle |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Surmontil |
100mg |
100 Capsule In 1 Bottle |
4 |
|
|
Y |
N |
Y |
$100 | N | $100 | N | $100 | N |
Sustiva |
50mg |
30 Capsule, Gelatin Coated In 1 Bottle |
4 |
90 |
30 |
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Sustiva |
200mg |
90 Capsule, Gelatin Coated In 1 Bottle |
5 |
60 |
30 |
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sustiva |
600mg |
30 Tablet, Film Coated In 1 Bottle |
5 |
30 |
30 |
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Sutent |
12.5mg |
28 Capsule In 1 Bottle |
5 |
90 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sutent |
25mg |
28 Capsule In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sutent |
50mg |
28 Capsule In 1 Bottle |
5 |
30 |
30 |
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sylatron |
|
1 Kit In 1 Carton |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sylatron |
|
1 Kit In 1 Carton |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sylatron |
|
1 Kit In 1 Carton |
5 |
|
|
Y |
N |
Y |
25% | N | 25% | N | 25% | N |
Sylvant |
100mg |
1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Symbicort |
160; 4.5ug/1; ug |
1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 120 Aerosol In 1 Canister |
3 |
10.2 |
30 |
N |
N |
Y |
$47 | N | $47 | N | $47 | N |
Synagis |
50mg/.5mL |
.5 Ml In 1 Vial, Single-dose |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Synarel |
2mg/mL |
1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Synercid |
350; 150mg/5mL; mg/5mL |
10 Vial, Glass In 1 Carton |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Synribo |
3.5mg/mL |
1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use |
5 |
|
|
N |
N |
Y |
25% | N | 25% | N | 25% | N |
Synthroid |
137ug |
90 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
25ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
50ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
75ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
88ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
100ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
125ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
150ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
175ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
200ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
300ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |
Synthroid |
112ug |
1000 Tablet In 1 Bottle |
4 |
|
|
N |
N |
Y |
$100 | N | $100 | N | $100 | N |