2016 First Health Part D Premier Plus (PDP) Formulary



Below is the Formulary, or drug list, for First Health Part D Premier Plus (PDP) from First Health Life & Health Insurance Company This formulary is a list of prescription medications that are covered under First Health Life & Health Insurance Company's 2016 Part-D Plan. The First Health Part D Premier Plus (PDP) plan has a $0 drug deductible. 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. First Health Part D Premier Plus (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.

See More on First Health Part D Premier Plus (PDP)





Plan Name:
First Health Part D Premier Plus (PDP)
Plan ID:
S5768-190
Provider: First Health Life & Health Insurance Company
Plan Year:2016
Premium:$72.60
Deductible:$0
Initial Coverage Limit:$3310
Coverage Area:Upper Midwest and Northern Plains (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming)




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
Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Sabril 500mg 100 Tablet, Film Coated In 1 Bottle
5
Y N 33%N33%N33%N
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
5
Y N 33%N33%N33%N
Samsca 15mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
30 30 Y N 33%N33%N33%N
Samsca 30mg 1 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
5
60 30 Y N 33%N33%N33%N
Sandimmune 100mg/mL 50 Ml In 1 Bottle
4
Y N 45%N45%N45%N
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
2
N N $2N$7N$7N
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
2
N N $2N$7N$7N
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
2
N N $2N$7N$7N
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
5
60 30 N N 33%N33%N33%N
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
5
120 30 N N 33%N33%N33%N
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
3
60 30 N N $40N$40N$40N
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
5
60 30 N N 33%N33%N33%N
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
5
120 30 N N 33%N33%N33%N
Serevent 50ug 60 Powder, Metered In 1 Inhaler
4
60 30 N N 45%N45%N45%N
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
3
180 30 N N $40N$40N$40N
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
3
30 30 N N $40N$40N$40N
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
30 30 N N $40N$40N$40N
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
3
60 30 N N $40N$40N$40N
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
3
60 30 N N $40N$40N$40N
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
1
N N $1N$6N$6N
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
N N $1N$6N$6N
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
1
N N $1N$6N$6N
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
N N $1N$6N$6N
Signifor .3mg/mL 60 Package In 1 Box
5
60 30 Y N 33%N33%N33%N
Signifor .6mg/mL 60 Package In 1 Box
5
60 30 Y N 33%N33%N33%N
Signifor .9mg/mL 60 Package In 1 Box
5
60 30 Y N 33%N33%N33%N
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
90 30 Y N $40N$40N$40N
Silenor 3mg 100 Tablet In 1 Bottle
3
30 30 N N $40N$40N$40N
Silenor 6mg 100 Tablet In 1 Bottle
3
30 30 N N $40N$40N$40N
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
2
N N $2N$7N$7N
Simbrinza 2; 10mg/mL; mg/mL 8 Ml In 1 Bottle, Dropper
4
N N 45%N45%N45%N
Simulect 20mg/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
1
N N $1N$6N$6N
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
1
N N $1N$6N$6N
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
N N $1N$6N$6N
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
N N $1N$6N$6N
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
1
30 30 N N $1N$6N$6N
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
3
Y N $40N$40N$40N
Sirturo 100mg 188 Tablet In 1 Bottle
5
188 365 Y N 33%N33%N33%N
Sivextro 200mg 10 Vial, Glass In 1 Carton > 1 Powder, For Solution In 1 Vial, Glass
5
N N 33%N33%N33%N
Sivextro 200mg 30 Tablet, Coated In 1 Bottle
5
N N 33%N33%N33%N
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
2
N N $2N$7N$7N
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
2
N N $2N$7N$7N
Sodium Chloride 3g/100mL 500 Ml In 1 Bag
2
N N $2N$7N$7N
Sodium Chloride 5g/100mL 500 Ml In 1 Bag
2
N N $2N$7N$7N
Sodium Chloride 2.92g/20mL 25 Vial In 1 Tray > 20 Ml In 1 Vial
2
N N $2N$7N$7N
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sodium Phenylbutyrate .94g/g 1 Bottle In 1 Carton > 250 G In 1 Bottle
5
Y N 33%N33%N33%N
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
2
N N $2N$7N$7N
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
4
Y N 45%N45%N45%N
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
5
0.20 28 Y N 33%N33%N33%N
Somatuline Depot 90mg/.3mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe
5
0.30 28 Y N 33%N33%N33%N
Somatuline Depot 120mg/.5mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe
5
0.50 28 Y N 33%N33%N33%N
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
Y N 33%N33%N33%N
Somavert 1 Kit In 1 Package
5
Y N 33%N33%N33%N
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
Y N 33%N33%N33%N
Sorine 80mg 100 Blister Pack In 1 Carton
2
N N $2N$7N$7N
Sorine 120mg 100 Blister Pack In 1 Carton
2
N N $2N$7N$7N
Sorine 160mg 100 Blister Pack In 1 Carton
2
N N $2N$7N$7N
Sorine 240mg 100 Blister Pack In 1 Carton
2
N N $2N$7N$7N
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
2
N N $2N$7N$7N
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
2
N N $2N$7N$7N
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
5
28 28 Y N 33%N33%N33%N
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
30 30 N N $40N$40N$40N
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $2N$7N$7N
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $2N$7N$7N
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $2N$7N$7N
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sporanox 10mg/mL 150 Ml In 1 Bottle
5
Y N 33%N33%N33%N
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N $2N$7N$7N
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60 30 Y N 33%N33%N33%N
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60 30 Y N 33%N33%N33%N
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60 30 Y N 33%N33%N33%N
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
60 30 Y N 33%N33%N33%N
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N $2N$7N$7N
Ssd Cream 10g/1000g 85 G In 1 Tube
2
N N $2N$7N$7N
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
3
N N $40N$40N$40N
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
3
N N $40N$40N$40N
Stavudine 30mg 60 Capsule In 1 Bottle
3
N N $40N$40N$40N
Stavudine 40mg 60 Capsule In 1 Bottle
3
N N $40N$40N$40N
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
2
N N $2N$7N$7N
Stivarga 40mg 3 Bottle, Plastic In 1 Box
5
120 30 Y N 33%N33%N33%N
Streptomycin 1g 10 Vial In 1 Box
2
N N $2N$7N$7N
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30 30 N N 33%N33%N33%N
Stromectol 3mg 2 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
3
N N $40N$40N$40N
Suboxone 2; .5mg/1; mg 30 Pouch In 1 Carton
4
90 30 Y N 45%N45%N45%N
Suboxone 4; 1mg/1; mg 30 Pouch In 1 Carton
4
90 30 Y N 45%N45%N45%N
Suboxone 8; 2mg/1; mg 30 Pouch In 1 Carton
4
90 30 Y N 45%N45%N45%N
Suboxone 12; 3mg/1; mg 30 Pouch In 1 Carton
4
60 30 Y N 45%N45%N45%N
Suclear 1 Kit In 1 Carton
4
N N 45%N45%N45%N
Sucralfate 1g 500 Tablet In 1 Bottle
2
N N $2N$7N$7N
Sulfacetamide Sodium 100mg/mL 118 Ml In 1 Bottle
2
N N $2N$7N$7N
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
2
N N $2N$7N$7N
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
2
N N $2N$7N$7N
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N $1N$6N$6N
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
1
N N $1N$6N$6N
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
1
N N $1N$6N$6N
Sulfamylon 85mg/g 1 Tube In 1 Carton > 113.4 G In 1 Tube
4
N N 45%N45%N45%N
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
2
N N $2N$7N$7N
Sumatriptan 20mg/100uL 6 Container In 1 Box
2
6 30 N N $2N$7N$7N
Sumatriptan 5mg/100uL 6 Container In 1 Box
2
6 30 N N $2N$7N$7N
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
9 30 N N $2N$7N$7N
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
9 30 N N $2N$7N$7N
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
2
4 30 N N $2N$7N$7N
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
9 30 N N $2N$7N$7N
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
2
4 30 N N $2N$7N$7N
Sumavel Dosepro 6mg/.5mL 6 Syringe, Glass In 1 Carton > .5 Ml In 1 Syringe, Glass
5
4 30 N Y 33%N33%N33%N
Suprax 100mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N 45%N45%N45%N
Suprax 200mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N 45%N45%N45%N
Suprax 200mg/5mL 75 Ml In 1 Bottle
4
N N 45%N45%N45%N
Suprax 500mg/5mL 20 Ml In 1 Bottle
4
N N 45%N45%N45%N
Suprax 400mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N 45%N45%N45%N
Suprax 100mg/5mL 50 Ml In 1 Bottle
4
N N 45%N45%N45%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 45%N45%N45%N
Surmontil 25mg 100 Capsule In 1 Bottle
4
Y N 45%N45%N45%N
Surmontil 50mg 100 Capsule In 1 Bottle
4
Y N 45%N45%N45%N
Surmontil 100mg 100 Capsule In 1 Bottle
4
Y N 45%N45%N45%N
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
4
N N 45%N45%N45%N
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
4
N N 45%N45%N45%N
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
4
N N 45%N45%N45%N
Sutent 12.5mg 28 Capsule In 1 Bottle
5
90 30 Y N 33%N33%N33%N
Sutent 25mg 28 Capsule In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sutent 50mg 28 Capsule In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sylatron 1 Kit In 1 Carton
5
Y N 33%N33%N33%N
Sylatron 1 Kit In 1 Carton
5
Y N 33%N33%N33%N
Sylatron 1 Kit In 1 Carton
5
Y N 33%N33%N33%N
Sylvant 100mg 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Symbicort 160; 4.5ug/1; ug 1 Pouch In 1 Carton > 1 Canister In 1 Pouch > 120 Aerosol In 1 Canister
3
10.20 30 N N $40N$40N$40N
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
5
Y N 33%N33%N33%N
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
5
N N 33%N33%N33%N
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
5
N N 33%N33%N33%N
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Synthroid 137ug 90 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 25ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 50ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 75ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 88ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 100ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 125ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 150ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 175ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 200ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 300ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N
Synthroid 112ug 1000 Tablet In 1 Bottle
3
N N $40N$40N$40N



Medicare Help's Additional Notes:

Coverage Levels for S5768-190

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 $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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