2016 Care Improvement Plus Dual Advantage (Regional PPO SNP) Formulary



Below is the Formulary, or drug list, for Care Improvement Plus Dual Advantage (Regional PPO SNP) from Care Improvement Plus South Central Insurance Co. This formulary is a list of prescription medications that are covered under Care Improvement Plus South Central Insurance Co.'s 2016 Medicare Advantage Plan. The Care Improvement Plus Dual Advantage (Regional PPO SNP) plan has a $360 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 $3310. 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 $3310 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 2016 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Care Improvement Plus Dual Advantage (Regional PPO 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.

See More on Care Improvement Plus Dual Advantage (Regional PPO SNP)





Plan Name:
Care Improvement Plus Dual Advantage (Regional PPO SNP)
Plan ID:
R9896-021
Provider: Care Improvement Plus South Central Insurance Co.
Plan Year:2016
Premium:$0.00
Deductible:$360
Initial Coverage Limit:$3310
Coverage Area:Georgia




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  T  U  V  W  X  Y  Z 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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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
Does the Deduct Apply Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Sabril 500mg 100 Tablet, Film Coated In 1 Bottle
5
180 30 Y N Y $0$7.40$0$7.40NAN
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
5
180 30 Y N Y $0$7.40$0$7.40NAN
Saizen 1 Kit In 1 Carton * 3 Ml In 1 Vial, Glass * 3.5 Ml In 1 Vial, Glass
5
Y N Y $0$7.40$0$7.40NAN
Saizen Clickeasy 1 Kit In 1 Carton * 1.51 Ml In 1 Vial, Glass * 1.51 Ml In 1 Cartridge
5
Y N Y $0$7.40$0$7.40NAN
Samsca 15mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
60 30 Y N Y $0$7.40$0$7.40NAN
Samsca 30mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
60 30 Y N Y $0$7.40$0$7.40NAN
Sancuso 3.1mg/24h 1 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
5
N N Y $0$7.40$0$7.40NAN
Sandimmune 100mg/mL 50 Ml In 1 Bottle
4
Y N Y $0$7.40$0$7.40NAN
Sandimmune 100mg 30 Blister Pack In 1 Package
5
Y N Y $0$7.40$0$7.40NAN
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
Y N Y $0$7.40$0$7.40NAN
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
Y N Y $0$7.40$0$7.40NAN
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
Y N Y $0$7.40$0$7.40NAN
Savella 1 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
N N Y $0$7.40$0$7.40NAN
Savella 100mg 60 Tablet, Film Coated In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Savella 12.5mg 60 Tablet, Film Coated In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Savella 25mg 60 Tablet, Film Coated In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Savella 50mg 60 Tablet, Film Coated In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
2
N N Y $0$7.40N$7.40NAN
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
5
90 30 N N Y $0$7.40$0$7.40NAN
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
5
180 30 N N Y $0$7.40$0$7.40NAN
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
3
60 30 N N Y $0$7.40$0$7.40NAN
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
5
60 30 N N Y $0$7.40$0$7.40NAN
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
5
120 30 N N Y $0$7.40$0$7.40NAN
Serevent 50ug 60 Powder, Metered In 1 Inhaler
3
60 30 N N Y $0$7.40$0$7.40NAN
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
3
60 30 N N Y $0$7.40$0$7.40NAN
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
3
30 30 N N Y $0$7.40$0$7.40NAN
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
30 30 N N Y $0$7.40$0$7.40NAN
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
3
60 30 N N Y $0$7.40$0$7.40NAN
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
60 30 N N Y $0$7.40$0$7.40NAN
Serostim 1 Kit In 1 Carton * 1 Ml In 1 Vial * 3.5 Ml In 1 Vial, Glass
5
Y N Y $0$7.40$0$7.40NAN
Serostim 1 Kit In 1 Carton * 1 Ml In 1 Vial * 1 Ml In 1 Vial
5
Y N Y $0$7.40$0$7.40NAN
Serostim 1 Kit In 1 Carton * 1 Ml In 1 Vial * 1 Ml In 1 Vial
5
Y N Y $0$7.40$0$7.40NAN
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
4
N N Y $0$7.40$0$7.40NAN
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
N N Y $0$2.95$0$2.95NAN
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
1
N N Y $0$2.95$0$2.95NAN
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
N N Y $0$2.95$0$2.95NAN
Sf Rowasa 4g/60mL 28 Bottle, With Applicator In 1 Carton
5
1800 30 N N Y $0$7.40$0$7.40NAN
Signifor .3mg/mL 60 Package In 1 Box
5
Y N Y $0$7.40$0$7.40NAN
Signifor .6mg/mL 60 Package In 1 Box
5
Y N Y $0$7.40$0$7.40NAN
Signifor .9mg/mL 60 Package In 1 Box
5
Y N Y $0$7.40$0$7.40NAN
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
90 30 Y N Y $0$7.40$0$7.40NAN
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
3
N N Y $0$7.40$0$7.40NAN
Simbrinza 2; 10mg/mL; mg/mL 8 Ml In 1 Bottle, Dropper
3
N N Y $0$7.40$0$7.40NAN
Simponi 50mg/.5mL 1 Syringe, Glass In 1 Carton > .5 Ml In 1 Syringe, Glass
5
Y N Y $0$7.40$0$7.40NAN
Simponi 100mg/mL 1 Syringe, Glass In 1 Carton > 1 Ml In 1 Syringe, Glass
5
Y N Y $0$7.40$0$7.40NAN
Simponi Aria 50mg/4mL 1 Vial, Single-use In 1 Carton > 4 Ml In 1 Vial, Single-use
5
Y N Y $0$7.40$0$7.40NAN
Simulect 20mg/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
5
N N Y $0$7.40$0$7.40NAN
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $0$2.95$0$2.95NAN
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $0$2.95$0$2.95NAN
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $0$2.95$0$2.95NAN
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $0$2.95$0$2.95NAN
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
1
30 30 N N Y $0$2.95$0$2.95NAN
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
4
Y N Y $0$7.40$0$7.40NAN
Sirturo 100mg 188 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
4
N N Y $0$7.40$0$7.40NAN
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
4
N N Y $0$7.40$0$7.40NAN
Sodium Chloride 3g/100mL 500 Ml In 1 Bag
4
N N Y $0$7.40$0$7.40NAN
Sodium Chloride 5g/100mL 500 Ml In 1 Bag
4
N N Y $0$7.40$0$7.40NAN
Sodium Chloride 2.92g/20mL 25 Vial In 1 Tray > 20 Ml In 1 Vial
4
N N Y $0$7.40$0$7.40NAN
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
3
N N Y $0$7.40$0$7.40NAN
Sodium Lactate 5.6g/10mL 25 Vial, Single-dose In 1 Tray > 10 Ml In 1 Vial, Single-dose
4
N N Y $0$7.40$0$7.40NAN
Sodium Phenylbutyrate .94g/g 1 Bottle In 1 Carton > 250 G In 1 Bottle
5
N N Y $0$7.40$0$7.40NAN
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Solaraze 30mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
5
Y N Y $0$7.40$0$7.40NAN
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
4
N N Y $0$7.40$0$7.40NAN
Solu-cortef 250mg/2mL 1 Vial, Single-dose In 1 Carton > 2 Ml In 1 Vial, Single-dose
4
N N Y $0$7.40$0$7.40NAN
Solu-medrol 1 Kit In 1 Carton * 30.6 Ml In 1 Vial * 30.6 Ml In 1 Vial
4
N N Y $0$7.40$0$7.40NAN
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
5
Y N Y $0$7.40$0$7.40NAN
Somatuline Depot 90mg/.3mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe
5
Y N Y $0$7.40$0$7.40NAN
Somatuline Depot 120mg/.5mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe
5
Y N Y $0$7.40$0$7.40NAN
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
Y N Y $0$7.40$0$7.40NAN
Somavert 1 Kit In 1 Package
5
Y N Y $0$7.40$0$7.40NAN
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
Y N Y $0$7.40$0$7.40NAN
Soriatane 10mg 30 Capsule In 1 Bottle
5
N N Y $0$7.40$0$7.40NAN
Soriatane 25mg 30 Capsule In 1 Bottle
5
N N Y $0$7.40$0$7.40NAN
Soriatane 17.5mg 30 Capsule In 1 Bottle
5
N N Y $0$7.40$0$7.40NAN
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
2
N N Y $0$7.40N$7.40NAN
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
2
N N Y $0$7.40N$7.40NAN
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
5
30 30 Y N Y $0$7.40$0$7.40NAN
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
30 30 N N Y $0$7.40$0$7.40NAN
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sporanox 10mg/mL 150 Ml In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
3
N N Y $0$7.40$0$7.40NAN
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
N N Y $0$7.40$0$7.40NAN
Ssd Cream 10g/1000g 85 G In 1 Tube
3
N N Y $0$7.40$0$7.40NAN
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
3
90 30 N N Y $0$7.40$0$7.40NAN
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
3
60 30 N N Y $0$7.40$0$7.40NAN
Stavudine 30mg 60 Capsule In 1 Bottle
3
90 30 N N Y $0$7.40$0$7.40NAN
Stavudine 40mg 60 Capsule In 1 Bottle
3
90 30 N N Y $0$7.40$0$7.40NAN
Stelara 45mg/.5mL 1 Syringe In 1 Carton > .5 Ml In 1 Syringe
5
Y N Y $0$7.40$0$7.40NAN
Stelara 90mg/mL 1 Syringe In 1 Carton > 1 Ml In 1 Syringe
5
Y N Y $0$7.40$0$7.40NAN
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
3
N N Y $0$7.40$0$7.40NAN
Stivarga 40mg 3 Bottle, Plastic In 1 Box
5
Y N Y $0$7.40$0$7.40NAN
Strattera 10mg 30 Capsule In 1 Bottle
4
60 30 N Y Y $0$7.40$0$7.40NAN
Strattera 25mg 30 Capsule In 1 Bottle
4
60 30 N Y Y $0$7.40$0$7.40NAN
Strattera 40mg 30 Capsule In 1 Bottle
4
60 30 N Y Y $0$7.40$0$7.40NAN
Strattera 18mg 30 Capsule In 1 Bottle
4
60 30 N Y Y $0$7.40$0$7.40NAN
Strattera 60mg 30 Capsule In 1 Bottle
4
30 30 N Y Y $0$7.40$0$7.40NAN
Strattera 80mg 30 Capsule In 1 Bottle
4
30 30 N Y Y $0$7.40$0$7.40NAN
Strattera 100mg 30 Capsule In 1 Bottle
4
30 30 N Y Y $0$7.40$0$7.40NAN
Streptomycin 1g 10 Vial In 1 Box
4
N N Y $0$7.40$0$7.40NAN
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
60 30 N N Y $0$7.40$0$7.40NAN
Suboxone 2; .5mg/1; mg 30 Pouch In 1 Carton
4
90 30 Y N Y $0$7.40$0$7.40NAN
Suboxone 4; 1mg/1; mg 30 Pouch In 1 Carton
4
60 30 Y N Y $0$7.40$0$7.40NAN
Suboxone 8; 2mg/1; mg 30 Pouch In 1 Carton
4
90 30 Y N Y $0$7.40$0$7.40NAN
Suboxone 12; 3mg/1; mg 30 Pouch In 1 Carton
4
60 30 Y N Y $0$7.40$0$7.40NAN
Sucraid 8500[iU]/mL 2 Bottle In 1 Carton
5
N N Y $0$7.40$0$7.40NAN
Sucralfate 1g 500 Tablet In 1 Bottle
2
N N Y $0$7.40N$7.40NAN
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
2
N N Y $0$7.40N$7.40NAN
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
2
N N Y $0$7.40N$7.40NAN
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
4
N N Y $0$7.40$0$7.40NAN
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
2
N N Y $0$7.40N$7.40NAN
Sulfamylon 85mg/g 1 Tube In 1 Carton > 113.4 G In 1 Tube
4
N N Y $0$7.40$0$7.40NAN
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
2
N N Y $0$7.40N$7.40NAN
Sumatriptan 20mg/100uL 6 Container In 1 Box
4
12 30 N N Y $0$7.40$0$7.40NAN
Sumatriptan 5mg/100uL 6 Container In 1 Box
4
12 30 N N Y $0$7.40$0$7.40NAN
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
3
9 30 N N Y $0$7.40$0$7.40NAN
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
3
9 30 N N Y $0$7.40$0$7.40NAN
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
4
6 30 N N Y $0$7.40$0$7.40NAN
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
3
9 30 N N Y $0$7.40$0$7.40NAN
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
4
6 30 N N Y $0$7.40$0$7.40NAN
Sumavel Dosepro 6mg/.5mL 6 Syringe, Glass In 1 Carton > .5 Ml In 1 Syringe, Glass
5
N N Y $0$7.40$0$7.40NAN
Suprax 100mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
3
N N Y $0$7.40$0$7.40NAN
Suprax 200mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
3
N N Y $0$7.40$0$7.40NAN
Suprax 200mg/5mL 75 Ml In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Suprax 500mg/5mL 20 Ml In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Suprax 400mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y $0$7.40$0$7.40NAN
Suprax 100mg/5mL 50 Ml In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
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 Y $0$7.40$0$7.40NAN
Surmontil 25mg 100 Capsule In 1 Bottle
4
Y N Y $0$7.40$0$7.40NAN
Surmontil 50mg 100 Capsule In 1 Bottle
4
Y N Y $0$7.40$0$7.40NAN
Surmontil 100mg 100 Capsule In 1 Bottle
4
Y N Y $0$7.40$0$7.40NAN
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
4
270 30 N N Y $0$7.40$0$7.40NAN
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
5
90 30 N N Y $0$7.40$0$7.40NAN
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
5
60 30 N N Y $0$7.40$0$7.40NAN
Sutent 12.5mg 28 Capsule In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sutent 25mg 28 Capsule In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sutent 50mg 28 Capsule In 1 Bottle
5
Y N Y $0$7.40$0$7.40NAN
Sylatron 1 Kit In 1 Carton
5
Y N Y $0$7.40$0$7.40NAN
Sylatron 1 Kit In 1 Carton
5
Y N Y $0$7.40$0$7.40NAN
Sylatron 1 Kit In 1 Carton
5
Y N Y $0$7.40$0$7.40NAN
Sylvant 100mg 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
5
Y N Y $0$7.40$0$7.40NAN
Symbicort 160; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 120 Aerosol In 1 Canister
3
N N Y $0$7.40$0$7.40NAN
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
5
Y N Y $0$7.40$0$7.40NAN
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
5
Y N Y $0$7.40$0$7.40NAN
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
5
N N Y $0$7.40$0$7.40NAN
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
Y N Y $0$7.40$0$7.40NAN
Synthroid 137ug 90 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 25ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 50ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 75ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 88ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 100ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 125ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 150ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 175ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 200ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 300ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN
Synthroid 112ug 1000 Tablet In 1 Bottle
3
N N Y $0$7.40$0$7.40NAN



Medicare Help's Additional Notes:

Coverage Levels for R9896-021

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $360. 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 $3310
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4850 in 2016.
4.Catastrophic: Anything over $4850 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 2016 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. 2015
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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