Drug List - S

S
Drug Name Tier Restrictions
SABRIL TAB 500MG 3 Prior Authorization
SAIZEN 3 Prior authorization, Step therapy
SALAGEN 2 Prior authorization, Quantity limit
SALEX 3 Quantity limit
SALSALATE 1
SANCTURA 3 Prior authorization
SANCTURA XR 3 Prior authorization
SANDOSTATIN INJ 3 Prior authorization
SANDOSTATIN LAR DEPOT KIT 3 Prior authorization
SANTYL 2 Quantity limit
SAPHRIS 3
SARNA LOT NC Quantity limit
SAVELLA 2
SAXENDA 3 Prior authorization
SEASONALE 3 Quantity limit
SEASONIQUE 3 Quantity limit
SELEGILINE HCL 1
SELENIUM SULFIDE LOTION 1 Quantity limit
SELENIUM SULFIDE SHA 3 Prior authorization, Quantity limit, Step therapy
SENSIPAR 2 Prior authorization
SEREVENT MIS 2 Quantity limit
SEROQUEL 3 Prior authorization
SEROQUEL XR 3 Prior authorization
SEROSTIM 3 Prior authorization, Step therapy
SERTRALINE HCL 1
SF 5000 PLUS 1 Quantity limit
SILDENAFIL 1 Quantity limit
SILENOR TAB 3 Prior authorization
SILVER NITRATE 1 Quantity limit
SILVER SULFA CRE 1% 1
SIMBRINZA SUS 1-0.2% 3
SIMCOR 2
SIMPONI 3 Prior authorization, Step therapy
SIMVASTATIN 1 Quantity limit
SINGULAIR 3 Prior authorization
SKELAXIN 3 Step therapy
SKLICE LOT 0.5% 3
SKYLA IUD $0
SMZ/TMP 1
SODIUM CHLORIDE INJ 1
SODIUM FLUORIDE 1*
SODIUM SULFACETAMIDE 1 Quantity limit
SODIUM SULFACETAMIDE AND SU EMU SULFUR 1 Quantity limit
SODIUM SULFACETAMIDE/SULFUR 1 Quantity limit
SOLODYN 3 Prior authorization, Step therapy
SOLU-CORTEF INJ 100MG UD $0
SOLU-MEDROL INJ 3 Prior authorization
SOLVADI 3 Prior authorization
SOMA 3 Prior authorization
SONATA CAP 3 Quantity limit, Step therapy
SOOLANTRA CRE 1% 3
SORBITOL 1
SORIATANE CK KIT 3 Prior authorization, Quantity limit
SOTALOL HCL 1
SPIRIVA 2 Quantity limit
SPIRONOLACTONE 1
SPIRONOLACTONE/HYDROCHLOROT 1
SPORANOX SOL 10MG/ML 3
SPRINTEC 1*
SPRYCEL 3 Prior authorization, Quantity limit, Step therapy
SRONYX 1*
SSKI 1
STALEVO 3 Prior authorization
STARLIX 2
STAVUDINE 1
STELARA 3 Prior authorization, Step therapy
STENDRA 3
STIMATE SOL 1.5MG/ML 3
STIOLTO AER 2.5-2.5 3
STRATTERA 3 Prior authorization
STRIBILD 2 Prior authorization
STROMECTOL 2
STRONGSTART CHW 3
SUBOXONE FILM 3
SUBOXONE SUB 3 Prior authorization
SUBUTEX SUB 2 Prior authorization
SUCRALFATE 1
SULAR 3 Prior authorization
SULFACET-R LOT TINT-FRE 3 Quantity limit
SULFACETAMIDE SODIUM 1
SULFACETAMIDE SODIUM OIN 1
SULFACETAMIDE SODIUM/SULFUR 1 Quantity limit
SULFADIAZINE 1
SULFATOL 3 Quantity limit
SULFAZINE EC 1
SULFUR SUBLIMED 1 Quantity limit
SULINDAC 1
SUMATRIPTAN 1 Quantity limit
SUPARTZ INJ 3 Quantity limit
SUPRAX 2
SUPREP 2
SURE COMFORT MIS LANCETS 1
SUSTIVA 2
SUTENT 2 Prior authorization, Quantity limit
SYMAX FASTABS 3 Prior authorization
SYMBICORT 2 Quantity limit
SYMLIN INJ 0.6MG/ML 2
SYNALAR 3 Quantity limit
SYNJARDY 2 Step therapy
SYNTHROID 1
SYNVISC INJ 2 Quantity limit
SYNVISC ONE INJ 2 Quantity limit
SYPRINE 2 Prior authorization
SYRINGES (VARIOUS) 1