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 
180 
30 
Y 
N 
33%  N  33%  N  33%  N 
Sabril 
50mg/mL 
50 Packet In 1 Carton > 10 Ml In 1 Packet 
5 
180 
30 
Y 
N 
33%  N  33%  N  33%  N 
Sandimmune 
100mg/mL 
50 Ml In 1 Bottle 
3 


Y 
N 
$30  N  $40  N  $30  N 
Sandostatin Lar Depot 

1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Singleuse 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sandostatin Lar Depot 

1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Singleuse 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sandostatin Lar Depot 

1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Singleuse 
5 


Y 
N 
33%  N  33%  N  33%  N 
Selegiline Hydrochloride 
5mg 
60 Capsule In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Selegiline Hydrochloride 
5mg 
500 Tablet In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Selenium Sulfide 
2.5mg/100mL 
118 Ml In 1 Bottle 
1 


N 
N 
$4  N  $9  N  $4  N 
Selzentry 
150mg 
60 Tablet, Film Coated In 1 Bottle 
5 


N 
N 
33%  N  33%  N  33%  N 
Selzentry 
300mg 
60 Tablet, Film Coated In 1 Bottle 
5 


N 
N 
33%  N  33%  N  33%  N 
Sensipar 
30mg 
30 Tablet, Coated In 1 Bottle, Plastic 
3 
120 
30 
N 
N 
$30  N  $40  N  $30  N 
Sensipar 
60mg 
30 Tablet, Coated In 1 Bottle, Plastic 
5 
60 
30 
N 
N 
33%  N  33%  N  33%  N 
Sensipar 
90mg 
30 Tablet, Coated In 1 Bottle, Plastic 
5 
120 
30 
N 
N 
33%  N  33%  N  33%  N 
Serevent 
50ug 
60 Powder, Metered In 1 Inhaler 
3 
60 
30 
N 
N 
$30  N  $40  N  $30  N 
Seroquel 
50mg 
100 Tablet, Extended Release In 1 Box, Unitdose 
4 
120 
30 
N 
N 
$70  N  $80  N  $70  N 
Seroquel 
150mg 
100 Tablet, Extended Release In 1 Dose Pack 
4 
30 
30 
N 
N 
$70  N  $80  N  $70  N 
Seroquel 
200mg 
10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack 
4 
30 
30 
N 
N 
$70  N  $80  N  $70  N 
Seroquel 
300mg 
60 Tablet, Extended Release In 1 Bottle 
4 
60 
30 
N 
N 
$70  N  $80  N  $70  N 
Seroquel 
400mg 
10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack 
4 
60 
30 
N 
N 
$70  N  $80  N  $70  N 
Sertraline Hydrochloride 
20mg/mL 
1 Bottle In 1 Carton > 60 Ml In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Sertraline Hydrochloride 
25mg 
30 Tablet In 1 Bottle 
1 
45 
30 
N 
N 
$4  N  $9  N  $4  N 
Sertraline Hydrochloride 
50mg 
30 Tablet In 1 Bottle 
1 
45 
30 
N 
N 
$4  N  $9  N  $4  N 
Sertraline Hydrochloride 
100mg 
30 Tablet In 1 Bottle 
1 


N 
N 
$4  N  $9  N  $4  N 
Signifor 
.3mg/mL 
60 Package In 1 Box 
5 


Y 
N 
33%  N  33%  N  33%  N 
Signifor 
.6mg/mL 
60 Package In 1 Box 
5 


Y 
N 
33%  N  33%  N  33%  N 
Signifor 
.9mg/mL 
60 Package In 1 Box 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sildenafil 
20mg 
90 Tablet, Film Coated In 1 Bottle, Plastic 
2 
90 
30 
Y 
N 
$9  N  $14  N  $9  N 
Silenor 
3mg 
100 Tablet In 1 Bottle 
3 
60 
30 
N 
N 
$30  N  $40  N  $30  N 
Silenor 
6mg 
100 Tablet In 1 Bottle 
3 
30 
30 
N 
N 
$30  N  $40  N  $30  N 
Silver Sulfadiazene 
10g/1000g 
50 G In 1 Jar 
2 


N 
N 
$9  N  $14  N  $9  N 
Simbrinza 
2; 10mg/mL; mg/mL 
8 Ml In 1 Bottle, Dropper 
3 


N 
N 
$30  N  $40  N  $30  N 
Simvastatin 
10mg 
30 Tablet, Film Coated In 1 Bottle 
1 
30 
30 
N 
N 
$4  N  $9  N  $4  N 
Simvastatin 
5mg 
90 Tablet, Film Coated In 1 Bottle 
1 
30 
30 
N 
N 
$4  N  $9  N  $4  N 
Simvastatin 
20mg 
500 Tablet, Film Coated In 1 Bottle 
1 
30 
30 
N 
N 
$4  N  $9  N  $4  N 
Simvastatin 
40mg 
500 Tablet, Film Coated In 1 Bottle 
1 
30 
30 
N 
N 
$4  N  $9  N  $4  N 
Simvastatin 
80mg 
1000 Tablet, Film Coated In 1 Bottle 
1 
30 
30 
N 
N 
$4  N  $9  N  $4  N 
Sirolimus 
.5mg 
100 Tablet, Film Coated In 1 Bottle 
2 


Y 
N 
$9  N  $14  N  $9  N 
Sirturo 
100mg 
188 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sivextro 
200mg 
10 Vial, Glass In 1 Carton > 1 Powder, For Solution In 1 Vial, Glass 
5 


N 
N 
33%  N  33%  N  33%  N 
Sivextro 
200mg 
30 Tablet, Coated In 1 Bottle 
5 


N 
N 
33%  N  33%  N  33%  N 
Sodium Chloride 
4.5g/1000mL 
1000 Ml In 1 Bag 
2 


N 
N 
$9  N  $14  N  $9  N 
Sodium Chloride 
9g/1000mL 
4 Bag In 1 Package > 100 Ml In 1 Bag 
2 


N 
N 
$9  N  $14  N  $9  N 
Sodium Chloride 
3g/100mL 
500 Ml In 1 Bag 
2 


N 
N 
$9  N  $14  N  $9  N 
Sodium Chloride 
5g/100mL 
500 Ml In 1 Bag 
2 


N 
N 
$9  N  $14  N  $9  N 
Sodium Chloride 
2.92g/20mL 
25 Vial In 1 Tray > 20 Ml In 1 Vial 
2 


N 
N 
$9  N  $14  N  $9  N 
Sodium Chloride 
900mg/100mL 
9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Sodium Phenylbutyrate 
.94g/g 
1 Bottle In 1 Carton > 250 G In 1 Bottle 
5 


N 
N 
33%  N  33%  N  33%  N 
Sodium Polystyrene Sulfonate 
15g/60mL 
473 Ml In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Soltamox 
10mg/5mL 
1 Bottle In 1 Carton > 150 Ml In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Solucortef 
250mg/2mL 
1 Vial, Singledose In 1 Carton > 2 Ml In 1 Vial, Singledose 
4 


N 
N 
$70  N  $80  N  $70  N 
Somatuline Depot 
60mg/.2mL 
1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe 
5 


Y 
N 
33%  N  33%  N  33%  N 
Somatuline Depot 
90mg/.3mL 
1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe 
5 


Y 
N 
33%  N  33%  N  33%  N 
Somatuline Depot 
120mg/.5mL 
1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe 
5 


Y 
N 
33%  N  33%  N  33%  N 
Somavert 

1 Kit In 1 Package * 1 Ml In 1 Vial, Singledose 
5 


Y 
N 
33%  N  33%  N  33%  N 
Somavert 

1 Kit In 1 Package 
5 


Y 
N 
33%  N  33%  N  33%  N 
Somavert 

1 Kit In 1 Package * 1 Ml In 1 Vial, Singledose 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sorine 
80mg 
100 Blister Pack In 1 Carton 
2 


N 
N 
$9  N  $14  N  $9  N 
Sorine 
120mg 
100 Blister Pack In 1 Carton 
2 


N 
N 
$9  N  $14  N  $9  N 
Sorine 
160mg 
100 Blister Pack In 1 Carton 
2 


N 
N 
$9  N  $14  N  $9  N 
Sorine 
240mg 
100 Blister Pack In 1 Carton 
2 


N 
N 
$9  N  $14  N  $9  N 
Sotalol Hydrochloride 
240mg 
100 Tablet In 1 Bottle 
1 


N 
N 
$4  N  $9  N  $4  N 
Sotalol Hydrochloride 
160mg 
100 Tablet In 1 Bottle 
1 


N 
N 
$4  N  $9  N  $4  N 
Sotalol Hydrochloride 
120mg 
100 Tablet In 1 Bottle, Plastic 
2 


N 
N 
$9  N  $14  N  $9  N 
Sotalol Hydrochloride 
80mg 
100 Tablet In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Sovaldi 
400mg 
28 Tablet, Film Coated In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Spironolactone 
100mg 
100 Tablet, Film Coated In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Spironolactone 
25mg 
100 Tablet, Film Coated In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Spironolactone 
50mg 
100 Tablet, Film Coated In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Spironolactone And Hydrochlorothiazide 
25; 25mg/1; mg 
500 Tablet In 1 Bottle, Plastic 
2 


N 
N 
$9  N  $14  N  $9  N 
Sprintec 

6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack 
2 


N 
N 
$9  N  $14  N  $9  N 
Sprycel 
70mg 
1 Bottle In 1 Carton > 60 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sprycel 
20mg 
1 Bottle In 1 Carton > 60 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sprycel 
50mg 
1 Bottle In 1 Carton > 60 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sprycel 
100mg 
1 Bottle In 1 Carton > 30 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sprycel 
80mg 
1 Bottle In 1 Carton > 30 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sprycel 
140mg 
1 Bottle In 1 Carton > 30 Tablet In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sronyx 

6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack 
2 


N 
N 
$9  N  $14  N  $9  N 
Ssd Cream 
10g/1000g 
85 G In 1 Tube 
2 


N 
N 
$9  N  $14  N  $9  N 
Stavudine 
15mg 
60 Capsule In 1 Bottle, Plastic 
2 


N 
N 
$9  N  $14  N  $9  N 
Stavudine 
20mg 
60 Capsule In 1 Bottle, Plastic 
2 


N 
N 
$9  N  $14  N  $9  N 
Stavudine 
30mg 
60 Capsule In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Stavudine 
40mg 
60 Capsule In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Sterile Water 
1mL/mL 
16 Container In 1 Case > 1000 Ml In 1 Container 
2 


N 
N 
$9  N  $14  N  $9  N 
Stivarga 
40mg 
3 Bottle, Plastic In 1 Box 
5 


Y 
N 
33%  N  33%  N  33%  N 
Strattera 
10mg 
30 Capsule In 1 Bottle 
4 
120 
30 
N 
N 
$70  N  $80  N  $70  N 
Strattera 
25mg 
30 Capsule In 1 Bottle 
4 
120 
30 
N 
N 
$70  N  $80  N  $70  N 
Strattera 
40mg 
30 Capsule In 1 Bottle 
4 
60 
30 
N 
N 
$70  N  $80  N  $70  N 
Strattera 
18mg 
30 Capsule In 1 Bottle 
4 
120 
30 
N 
N 
$70  N  $80  N  $70  N 
Strattera 
60mg 
30 Capsule In 1 Bottle 
4 
30 
30 
N 
N 
$70  N  $80  N  $70  N 
Strattera 
80mg 
30 Capsule In 1 Bottle 
4 
30 
30 
N 
N 
$70  N  $80  N  $70  N 
Strattera 
100mg 
30 Capsule In 1 Bottle 
4 
30 
30 
N 
N 
$70  N  $80  N  $70  N 
Streptomycin 
1g 
10 Vial In 1 Box 
2 


N 
N 
$9  N  $14  N  $9  N 
Stribild 
150; 150; 200; 300mg/1; mg/1; mg/1; mg 
30 Tablet, Film Coated In 1 Bottle, Plastic 
5 


N 
N 
33%  N  33%  N  33%  N 
Suboxone 
2; .5mg/1; mg 
30 Pouch In 1 Carton 
4 
120 
30 
Y 
N 
$70  N  $80  N  $70  N 
Suboxone 
4; 1mg/1; mg 
30 Pouch In 1 Carton 
4 
120 
30 
Y 
N 
$70  N  $80  N  $70  N 
Suboxone 
8; 2mg/1; mg 
30 Pouch In 1 Carton 
4 
120 
30 
Y 
N 
$70  N  $80  N  $70  N 
Suboxone 
12; 3mg/1; mg 
30 Pouch In 1 Carton 
4 
60 
30 
Y 
N 
$70  N  $80  N  $70  N 
Sucraid 
8500[iU]/mL 
2 Bottle In 1 Carton 
5 


N 
N 
33%  N  33%  N  33%  N 
Sucralfate 
1g 
500 Tablet In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulfacetamide Sodium 
100mg/mL 
118 Ml In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulfacetamide Sodium 
100mg/mL 
1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulfacetamide Sodium And Prednisolone Sodium Phosp 
2.5; 100mg/mL; mg/mL 
10 Ml In 1 Bottle 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulfamethoxazole And Trimethoprim 
400; 80mg/1; mg 
500 Tablet In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Sulfamethoxazole And Trimethoprim 
80; 16mg/mL; mg/mL 
10 Vial, Multidose In 1 Carton 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulfamethoxazole And Trimethoprim 
800; 160mg/1; mg 
100 Tablet In 1 Bottle 
1 


N 
N 
$4  N  $9  N  $4  N 
Sulfamylon 
85mg/g 
1 Tube In 1 Carton > 113.4 G In 1 Tube 
4 


N 
N 
$70  N  $80  N  $70  N 
Sulfamylon 
50g 
5 Packet In 1 Carton 
5 


N 
N 
33%  N  33%  N  33%  N 
Sulfasalazine 
500mg 
500 Tablet In 1 Bottle, Plastic 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulfasalazine 
500mg 
300 Tablet, Delayed Release In 1 Bottle, Plastic 
2 


N 
N 
$9  N  $14  N  $9  N 
Sulindac 
150mg 
100 Tablet In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Sulindac 
200mg 
500 Tablet In 1 Bottle, Plastic 
1 


N 
N 
$4  N  $9  N  $4  N 
Sumatriptan 
20mg/100uL 
6 Container In 1 Box 
2 
12 
30 
N 
N 
$9  N  $14  N  $9  N 
Sumatriptan 
5mg/100uL 
6 Container In 1 Box 
2 
24 
30 
N 
N 
$9  N  $14  N  $9  N 
Sumatriptan 
100mg 
1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack 
2 
9 
30 
N 
N 
$9  N  $14  N  $9  N 
Sumatriptan 
50mg 
1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack 
2 
9 
30 
N 
N 
$9  N  $14  N  $9  N 
Sumatriptan Succinate 
6mg/.5mL 
2 Syringe In 1 Package > .5 Ml In 1 Syringe 
2 
6 
30 
N 
N 
$9  N  $14  N  $9  N 
Sumatriptan Succinate 
25mg 
9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack 
2 
9 
30 
N 
N 
$9  N  $14  N  $9  N 
Sumatriptan Succinate 
6mg/.5mL 
1 Vial, Singledose In 1 Carton > .5 Ml In 1 Vial, Singledose 
2 
6 
30 
N 
N 
$9  N  $14  N  $9  N 
Suprax 
100mg 
1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack 
4 


N 
N 
$70  N  $80  N  $70  N 
Suprax 
200mg 
1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack 
4 


N 
N 
$70  N  $80  N  $70  N 
Suprax 
500mg/5mL 
20 Ml In 1 Bottle 
3 


N 
N 
$30  N  $40  N  $30  N 
Suprax 
400mg 
1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack 
3 


N 
N 
$30  N  $40  N  $30  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 
$70  N  $80  N  $70  N 
Surmontil 
25mg 
100 Capsule In 1 Bottle 
4 
240 
30 
Y 
N 
$70  N  $80  N  $70  N 
Surmontil 
50mg 
100 Capsule In 1 Bottle 
4 
120 
30 
Y 
N 
$70  N  $80  N  $70  N 
Surmontil 
100mg 
100 Capsule In 1 Bottle 
4 
60 
30 
Y 
N 
$70  N  $80  N  $70  N 
Sustiva 
50mg 
30 Capsule, Gelatin Coated In 1 Bottle 
3 


N 
N 
$30  N  $40  N  $30  N 
Sustiva 
200mg 
90 Capsule, Gelatin Coated In 1 Bottle 
3 


N 
N 
$30  N  $40  N  $30  N 
Sustiva 
600mg 
30 Tablet, Film Coated In 1 Bottle 
5 


N 
N 
33%  N  33%  N  33%  N 
Sutent 
12.5mg 
28 Capsule In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sutent 
25mg 
28 Capsule In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sutent 
50mg 
28 Capsule In 1 Bottle 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sylatron 

1 Kit In 1 Carton 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sylatron 

1 Kit In 1 Carton 
5 


Y 
N 
33%  N  33%  N  33%  N 
Sylatron 

1 Kit In 1 Carton 
5 


Y 
N 
33%  N  33%  N  33%  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 
$30  N  $40  N  $30  N 
Synagis 
50mg/.5mL 
.5 Ml In 1 Vial, Singledose 
5 


N 
N 
33%  N  33%  N  33%  N 
Synarel 
2mg/mL 
1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray 
5 


N 
N 
33%  N  33%  N  33%  N 
Synercid 
350; 150mg/5mL; mg/5mL 
10 Vial, Glass In 1 Carton 
5 


N 
N 
33%  N  33%  N  33%  N 
Synribo 
3.5mg/mL 
1 Vial, Singleuse In 1 Carton > 1 Ml In 1 Vial, Singleuse 
5 


Y 
N 
33%  N  33%  N  33%  N 
Synthroid 
137ug 
90 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
25ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
50ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
75ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
88ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
100ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
125ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
150ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
175ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
200ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
300ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 
Synthroid 
112ug 
1000 Tablet In 1 Bottle 
4 


N 
N 
$70  N  $80  N  $70  N 