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MassHealth Drug List A - Z


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This is a listing of all of the drugs covered by MassHealth. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for.



MassHealth Drug List table
Drug - Brand Name (Generic Name) PA Status Class Drug Notes
Sitavig (acyclovir buccal tablet)drugId:2945 PA ANTIVIRALS
Scemblix (asciminib)drugId:8210 PA CHEMOTHERAPY
Secuado (asenapine transdermal); See Table 24drugId:7354; See Table 71drugId:7355 PA ANTIPSYCHOTIC
Strensiq (asfotase alfa)drugId:5300 PA ENZYMES
Sirturo (bedaquiline)drugId:2851 PA TB PREPARATIONS
Sernivo (betamethasone dipropionate spray)drugId:5396 PA GLUCOCORTICOIDS
Simbrinza (brinzolamide / brimonidine)drugId:2849 OPHTHALMIC PREPARATIONS
Siliq (brodalumab)drugId:6042 PA IMMUNOMODULATOR
Soma (carisoprodol)drugId:180 PA MUSCLE RELAXANT
Seglentis (celecoxib / tramadol)drugId:8211 PA ANALGESICS
Sympazan (clobazam film)drugId:7106 PA ANTICONVULSANTS
Sevenfact (coagulation factor VIIa, recombinant)drugId:8561 ANTI-HEMOPHILIA AGENTS
Santyl (collagenase)drugId:8414 PA DERMATOLOGICAL
Spikevax (COVID-19 Moderna vaccine, COVID EUA – September 11, 2023 for members ≥ 6 months of age)drugId:8312 COVID - 19 related Treatments and Vaccines
Sandimmune (cyclosporine solution)drugId:8049 PA IMMUNOMODULATOR
Synercid (dalfopristin / quinupristin)drugId:2037 PA ANTIBIOTICS
Sotyktu (deucravacitinib)drugId:8370 PA IMMUNOMODULATOR
Slynd (drospirenone) CONTRACEPTIVES
Savaysa (edoxaban)drugId:4795 PA ANTICOAGULANTS
Stribild (elvitegravir / cobicistat / emtricitabine / tenofovir disoproxil fumarate)drugId:2648 ANTIVIRALS
Synjardy (empagliflozin / metformin)drugId:5113 DIABETIC AGENTS
Synjardy XR (empagliflozin / metformin extended-release)drugId:6107 DIABETIC AGENTS
Symjepi (epinephrine injection)drugId:7105 ADRENERGICS
Steglatro (ertugliflozin)drugId:6617 PA DIABETIC AGENTS
Segluromet (ertugliflozin / metformin)drugId:6616 PA DIABETIC AGENTS
Steglujan (ertugliflozin / sitagliptin)drugId:6618 PA DIABETIC AGENTS
Spravato (esketamine); See Table 17drugId:7138; See Table 71drugId:7139 PA ANTIDEPRESSANTS
Synalar (fluocinolone cream kit)drugId:5062 PA GLUCOCORTICOIDS
Synalar (fluocinolone ointment kit)drugId:5063 PA GLUCOCORTICOIDS
Synalar (fluocinolone solution kit)drugId:5064 PA GLUCOCORTICOIDS
Simponi (golimumab)drugId:681 PA IMMUNOMODULATOR
Simponi Aria (golimumab for infusion)drugId:2850 PA IMMUNOMODULATOR
Sustol (granisetron extended-release injection)drugId:5767 PA > 2 units/28 days ANTIEMETICS
Sancuso (granisetron transdermal system)drugId:685 PA ANTIEMETICS
Supprelin LA (histrelin)drugId:710 PA HORMONE AGENTS
Solu-Cortef (hydrocortisone injection)drugId:729 GLUCOCORTICOIDS
Siklos (hydroxyurea tablet)drugId:6821 PA HEMATOLOGIC
Soliqua (insulin glargine / lixisenatide)drugId:5766 PA DIABETIC AGENTS
Semglee (insulin glargine-yfgn)drugId:7470 PA DIABETIC AGENTS
Sprix (ketorolac nasal spray)drugId:2289 PA NONSTEROIDAL ANTI-INFLAMMATORY
Somatuline (lanreotide)drugId:1020 ENDOCRINE/METABOLIC AGENTS
Sunlenca (lenacapavir)drugId:8580 PA ANTIVIRALS
Spritam (levetiracetam tablet for oral suspension)drugId:5397 PA ANTICONVULSANTS
Skyla (levonorgestrel-releasing intrauterine system 13.5 mg) CONTRACEPTIVES
Synera (lidocaine / tetracaine)drugId:1075 PA > 4 patches/30 days ANESTHETICS
Selzentry (maraviroc solution)drugId:7577 PA ANTIVIRALS
Savella (milnacipran) ANALGESICS
Sinuva (mometasone sinus implant)drugId:6684 PA NASAL PREPARATIONS
Synarel (nafarelin)drugId:1420 PA HORMONE AGENTS
Symproic (naldemedine)drugId:6619 PA CONSTIPATION AGENTS
Sandostatin LAR (octreotide injectable suspension)drugId:2497 ENDOCRINE/METABOLIC AGENTS
Striverdi (olodaterol)drugId:4641 PA BRONCHODILATORS
Synribo (omacetaxine mepesuccinate)drugId:2659 PA CHEMOTHERAPY
Skyclarys (omaveloxolone)drugId:8579 PA UNCLASSIFIED DRUG PRODUCTS
Synagis (palivizumab)drugId:1472 PA ANTIVIRALS
Sohonos (palovarotene)drugId:8785 PA MISCELLANEOUS
Signifor (pasireotide)drugId:2791 PA ENDOCRINE/METABOLIC AGENTS
Stimufend (pegfilgrastim-fpgk)drugId:8541 HEMATINICS & BLOOD CELL STIMULATORS
Somavert (pegvisomant)drugId:1491 PA HORMONE AGENTS
Suflave (polyethylene glycol / sodium sulfate / potassium chloride / magnesium sulfate / sodium chloride)drugId:8786 PA LAXATIVES
SSKI (potassium iodide)drugId:8421 PA > 1 mL/day IODINE THERAPY
Symlinpen (pramlintide)drugId:1570 DIABETIC AGENTS
Stivarga (regorafenib)drugId:2646 PA CHEMOTHERAPY
Skyrizi (risankizumab-rzaa)drugId:7227 PA IMMUNOMODULATOR
saccharomyces boulardiidrugId:6207 PA ≥ 22 years GASTROINTESTINAL AGENT
sacrosidasedrugId:8409 PA UNCLASSIFIED DRUG PRODUCTS
Sucraid (sacrosidase)drugId:8409 PA UNCLASSIFIED DRUG PRODUCTS
sacubitril / valsartandrugId:5125 PA CARDIOVASCULAR
safinamidedrugId:6185 PA ANTIPARKINSON
salmeteroldrugId:1829 BRONCHODILATORS
Serevent (salmeterol)drugId:1829 BRONCHODILATORS
sapropterindrugId:1831 PA ENZYMES
saquinavirdrugId:1832 ANTIVIRALS
sargramostimdrugId:1833 HEMATINIC AGENT
sarilumabdrugId:6181 PA IMMUNOMODULATOR
satralizumab-mwgedrugId:7525 PA BIOLOGICAL
secnidazoledrugId:6523 PA ANTIBIOTICS
Solosec (secnidazole)drugId:6523 PA ANTIBIOTICS
secukinumabdrugId:4908 PA IMMUNOMODULATOR
segesterone / ethinyl estradiol CONTRACEPTIVES
selegiline orally disintegrating tabletdrugId:1839 PA ANTIPARKINSON
selegiline transdermal patch; See Table 17drugId:1840; See Table 71drugId:3560 PA ANTIDEPRESSANTS
selexipagdrugId:5401 PA CARDIOVASCULAR
selinexordrugId:7300 PA CHEMOTHERAPY
selpercatinibdrugId:7456 PA CHEMOTHERAPY
selumetinibdrugId:7467 PA CHEMOTHERAPY
semaglutide injection-OzempicdrugId:6613 PA DIABETIC AGENTS
semaglutide tabletdrugId:7427 PA DIABETIC AGENTS
serdexmethylphenidate / dexmethylphenidate; See Table 31drugId:7977; See Table 71drugId:7978 PA CEREBRAL STIMULANTS
sertaconazoledrugId:1843 FUNGICIDES
setmelanotidedrugId:7724 PA BIOLOGICAL
short ragweed pollen allergen extractdrugId:8504 PA ALLERGENS
sildenafil oral suspension-LiqrevdrugId:8713 PA CARDIOVASCULAR
sinecatechinsdrugId:1856 PA ANTIVIRALS
siponimoddrugId:7184 PA SPHINGOSINE 1-PHOSPHATE RECEPTOR MODULATOR
sirolimus geldrugId:8333 PA IMMUNOMODULATOR
sirolimus injectiondrugId:8298 PA IMMUNOMODULATOR
sitagliptindrugId:1858 DIABETIC AGENTS
sitagliptin / metformindrugId:1859 DIABETIC AGENTS
sitagliptin / metformin extended-releasedrugId:2485 DIABETIC AGENTS
sodium chloride 3.5%, 7% for inhalation - Non-Drug Product NON-DRUG PRODUCT
sodium chloride 6% for inhalation - Non-Drug Product NON-DRUG PRODUCT
sodium chloride 7% for inhalation - Non-Drug Product NON-DRUG PRODUCT
sodium chloride solution ELECTROLYTES AND NUTRIENTS
sodium phenylbutyrate / sodium taurursodioldrugId:8577 PA AMYOTROPHIC LATERAL SCLEROSIS AGENTS
sodium phenylbutyrate granulesdrugId:8369 PA ENZYMES
sodium phenylbutyrate pellets for suspensiondrugId:8659 PA ENZYMES
sodium phosphatedrugId:1873 LAXATIVES
sodium picosulfate / magnesium oxide / anhydrous citric acid-ClenpiqdrugId:6380 PA LAXATIVES
sodium polystyrene sulfonatedrugId:1874 CHELATING AGENT
sodium sulfate / magnesium sulfate / potassium chloridedrugId:7600 PA LAXATIVES
Sutab (sodium sulfate / magnesium sulfate / potassium chloride)drugId:7600 PA LAXATIVES
sodium zirconium cyclosilicatedrugId:6905 PA > 1 unit/day CHELATING AGENT
sofosbuvirdrugId:2879 PA ANTIVIRALS
Sovaldi (sofosbuvir)drugId:2879 PA ANTIVIRALS
sofosbuvir / velpatasvir / voxilaprevirdrugId:6364 PA ANTIVIRALS
solifenacin suspensiondrugId:7887 PA ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
solriamfetoldrugId:7267 PA NARCOLEPSY AGENTS
Sunosi (solriamfetol)drugId:7267 PA NARCOLEPSY AGENTS
somapacitan-becodrugId:8647 PA HORMONE AGENTS
Sogroya (somapacitan-beco)drugId:8647 PA HORMONE AGENTS
somatrogon-ghladrugId:8715 PA HORMONE AGENTS
somatropin-HumatropedrugId:1881 PA HORMONE AGENTS
somatropin-NorditropindrugId:1882 PA HORMONE AGENTS
somatropin-Nutropin AQdrugId:1884 PA HORMONE AGENTS
somatropin-OmnitropedrugId:1885 PA HORMONE AGENTS
somatropin-SaizendrugId:1886 PA HORMONE AGENTS
Saizen (somatropin-Saizen)drugId:1886 PA HORMONE AGENTS
somatropin-SerostimdrugId:1887 PA HORMONE AGENTS
Serostim (somatropin-Serostim)drugId:1887 PA HORMONE AGENTS
somatropin-ZomactondrugId:5002 PA HORMONE AGENTS
sonidegibdrugId:5284 PA CHEMOTHERAPY
sotagliflozindrugId:8722 PA DIABETIC AGENTS
sotalol solutiondrugId:4913 PA CARDIOVASCULAR
Sotylize (sotalol solution)drugId:4913 PA CARDIOVASCULAR
sotorasibdrugId:7980 PA CHEMOTHERAPY
sparsentandrugId:8706 PA OTHER ANTIHYPERTENSIVES
spesolimab-sbzodrugId:8371 PA IMMUNOMODULATOR
Spevigo (spesolimab-sbzo)drugId:8371 PA IMMUNOMODULATOR
stiripentoldrugId:7132 PA ANTICONVULSANTS
streptomycindrugId:2496 ANTIBIOTICS
succimer CHELATING AGENT
sucroferric oxyhydroxide ELECTROLYTES AND NUTRIENTS
sufentanil injectiondrugId:2566 OPIOID ANALGESICS
sulfamethoxazole / trimethoprim injectiondrugId:5661 ANTIBIOTICS
sumatriptan 10 mg nasal spraydrugId:7335 PA TRIPTAN
sumatriptan injection-ImitrexdrugId:1914 PA TRIPTAN
sumatriptan injection-ZembracedrugId:5599 PA TRIPTAN
suvorexant; See Table 15drugId:4903; See Table 71drugId:4904 PA SEDATIVE, NON-BARBITURATE
Soltamox (tamoxifen solution)drugId:4980 CHEMOTHERAPY
Sivextro (tedizolid injection)drugId:4636 PA ANTIBIOTICS
Sivextro (tedizolid tablet)drugId:4635 PA ANTIBIOTICS
Stiolto (tiotropium / olodaterol)drugId:5112 PA BRONCHODILATORS
Spiriva Respimat (tiotropium inhalation solution)drugId:8057 BRONCHODILATORS
Stamaril (yellow fever vaccine, live)drugId:6106 BIOLOGICAL
Shingrix (zoster vaccine recombinant, adjuvanted)drugId:6407 PA < 50 years BIOLOGICAL
Saphris (asenapine sublingual tablet); See Table 24drugId:97; See Table 71drugId:4260 PA ANTIPSYCHOTIC A90
Suprax (cefixime)drugId:196 PA ANTIBIOTICS A90
Symfi Lo (efavirenz 400 mg / lamivudine 300 mg / tenofovir disoproxil fumarate 300 mg)drugId:6783 PA ANTIVIRALS A90
Symfi (efavirenz 600 mg / lamivudine 300 mg / tenofovir disoproxil fumarate 300 mg)drugId:6782 PA ANTIVIRALS A90
Skelaxin (metaxalone)drugId:1156 PA MUSCLE RELAXANT A90
Symbyax (olanzapine / fluoxetine); See Table 17drugId:2058; See Table 24drugId:1279; See Table 71drugId:4264 PA ANTIDEPRESSANTS A90
salsalatedrugId:1830 PA NONSTEROIDAL ANTI-INFLAMMATORY A90
scopolamine ANTISPASMODICS,ANTICHOLINERGIC A90
selegiline capsule, tabletdrugId:2378 ANTIPARKINSON A90
sertraline capsule; See Table 17drugId:8125; See Table 71drugId:8126 PA ANTIDEPRESSANTS A90
sildenafil 20 mg tabletdrugId:1848 PA CARDIOVASCULAR A90
silver sulfadiazinedrugId:1852 ANTIBIOTICS A90
sodium citrate / citric acid ELECTROLYTES AND NUTRIENTS A90
sodium fluoride oral rinse ELECTROLYTES AND NUTRIENTS A90
spinosaddrugId:2239 PA ANTIPARASITICS A90
stavudinedrugId:1894 ANTIVIRALS A90
sulfacetamide / prednisolone sodium phosphate ophthalmic solutiondrugId:2272 OPHTHALMIC PREPARATIONS A90
sulfacetamide ophthalmic ointment, solutiondrugId:1901 OPHTHALMIC PREPARATIONS A90
sulfadiazinedrugId:1906 ANTIBIOTICS A90
sulindacdrugId:1912 NONSTEROIDAL ANTI-INFLAMMATORY A90
sumatriptan / naproxendrugId:1916 PA TRIPTAN/NON STEROIDAL ANTI-INFLAMMATORY A90
Strattera (atomoxetine); See Table 31drugId:104; See Table 71drugId:3080 PA < 6 years NONSTIMULANT ADHD AGENTS A90, #
StalevodrugId:176 (carbidopa / levodopa / entacapone)drugId:176 ANTIPARKINSON A90, #
SinemetdrugId:175 (carbidopa / levodopa tablet)drugId:175 ANTIPARKINSON A90, #
Sensipar (cinacalcet) CALCIMIMETIC A90, #
SandimmunedrugId:2092 (cyclosporine capsule)drugId:2092 IMMUNOMODULATOR A90, #
SustivadrugId:590 (efavirenz)drugId:590 ANTIVIRALS A90, #
SynalardrugId:5060 (fluocinolone 0.025% cream)drugId:5060 GLUCOCORTICOIDS A90, #
SynalardrugId:5061 (fluocinolone ointment)drugId:5061 GLUCOCORTICOIDS A90, #
SynalardrugId:2632 (fluocinolone solution)drugId:2632 GLUCOCORTICOIDS A90, #
SporanoxdrugId:988 (itraconazole 100 mg capsule)drugId:988 FUNGICIDES A90, #
SulfamylondrugId:1113 (mafenide)drugId:1113 ANTIBIOTICS A90, #
Seroquel (quetiapine); See Table 24drugId:1618; See Table 71drugId:4293 PA < 6 years and PA > 3 units/day ANTIPSYCHOTIC A90, #
Seroquel XR (quetiapine extended-release); See Table 24drugId:1616; See Table 71drugId:4295 PA < 6 years and PA > 2 units/day ANTIPSYCHOTIC A90, #
sertraline oral concentrate, tablet; See Table 17drugId:1845; See Table 71drugId:3820 PA < 6 years ANTIDEPRESSANTS A90, #
sevelamer carbonate ELECTROLYTES AND NUTRIENTS A90, #
sevelamer hydrochloride ELECTROLYTES AND NUTRIENTS A90, #
silver sulfadiazine-SilvadenedrugId:1850 ANTIBIOTICS A90, #
SilvadenedrugId:1850 (silver sulfadiazine-Silvadene)drugId:1850 ANTIBIOTICS A90, #
sirolimus solution, tabletdrugId:1857 IMMUNOMODULATOR A90, #
solifenacin tabletdrugId:1879 URINARY ANTISPASMODICS A90, #
sucralfate tablet ANTACIDS A90, #
sulfacetamide 10% lotiondrugId:1899 PA ≥ 22 years DERMATOLOGICAL A90, #
sulfamethoxazole / trimethoprim suspensiondrugId:5133 ANTIBIOTICS A90, #
SulfatrimdrugId:5133 (sulfamethoxazole / trimethoprim suspension)drugId:5133 ANTIBIOTICS A90, #
sulfasalazinedrugId:1910 GI ANTI-INFLAMMATORY A90, #
sulfasalazine delayed-releasedrugId:4864 GI ANTI-INFLAMMATORY A90, #
sumatriptan 5 mg, 20 mg nasal spraydrugId:1913 PA > 18 units/30 days TRIPTAN A90, #
sumatriptan tabletdrugId:1915 PA > 18 units/30 days TRIPTAN A90, #
Singulair (montelukast granules)drugId:5129 PA BRONCHODILATORS M90
Sular (nisoldipine)drugId:1219 PA CARDIOVASCULAR M90
silodosindrugId:1849 PA BENIGN PROSTATIC HYPERPLASIA AGENTS M90
spironolactone / hydrochlorothiazidedrugId:1893 CARDIOVASCULAR M90
spironolactone suspensiondrugId:6280 PA ALDOSTERONE ANTAGONISTS M90
Safyral (ethinyl estradiol / drospirenone / levomefolate-Safyral) CONTRACEPTIVES M90, #
Seasonique (levonorgestrel / ethinyl estradiol-Seasonique) CONTRACEPTIVES M90, #
Synthroid (levothyroxine-Synthroid) THYROID PREPARATIONS M90, #
SingulairdrugId:1383 (montelukast tablet, chewable tablet)drugId:1383 BRONCHODILATORS M90, #
simvastatin 5 mg, 10 mg, 20 mg, 40 mgdrugId:2737 PA > 1.5 units/day LIPID LOWERING AGENTS M90, #
simvastatin 80 mgdrugId:1855 PA > 1 unit/day LIPID LOWERING AGENTS M90, #
sotalol tabletdrugId:1891 CARDIOVASCULAR M90, #
spironolactone tabletdrugId:1892 ALDOSTERONE ANTAGONISTS M90, #
Skysona (elivaldogene autotemcel)drugId:8652 PA GENE THERAPY CO, MB
Sublocade (buprenorphine extended-release injection-Sublocade)drugId:6524 ALCOHOL AND DRUG CESSATION AGENT PD
Symtuza (darunavir / cobicistat / emtricitabine / tenofovir alafenamide)drugId:6822 ANTIVIRALS PD
Saxenda (liraglutide-Saxenda)drugId:8670 PA ANTI-OBESITY AGENTS PD
Skytrofa (lonapegsomatropin-tcgd)drugId:8158 PA HORMONE AGENTS PD
semaglutide injection-WegovydrugId:8671 PA ANTI-OBESITY AGENTS PD
sofosbuvir / velpatasvirdrugId:5540 PA ANTIVIRALS PD
somatropin-GenotropindrugId:1880 PA HORMONE AGENTS PD
Symdeko (tezacaftor / ivacaftor)drugId:6540 PA CYSTIC FIBROSIS AGENTS PD
Stelara (ustekinumab 45 mg/0.5 mL prefilled syringe, 90 mg/mL prefilled syringe, 45 mg/0.5 mL vial)drugId:1777 PA IMMUNOMODULATOR PD
Sprycel (dasatinib)drugId:331 CHEMOTHERAPY BP
sodium oxybatedrugId:1870 PA SEDATIVES BP
Symbicort (budesonide / formoterol)drugId:383 BRONCHODILATORS BP, A90
Sorilux (calcipotriene foam)drugId:2560 PA DERMATOLOGICAL BP, A90
Sporanox (itraconazole solution)drugId:7060 FUNGICIDES BP, A90
Selzentry (maraviroc tablet)drugId:1119 PA ANTIVIRALS BP, A90
Solodyn (minocycline extended-release 55 mg, 65 mg, 80 mg, 105 mg, 115 mg tablet)drugId:1364 ANTIBIOTICS BP, A90
scopolamine transdermal patchdrugId:1835 ANTIEMETICS BP, A90
sildenafil oral suspension-RevatiodrugId:4793 PA CARDIOVASCULAR BP, A90
sodium phenylbutyrate powder, tabletdrugId:1871 ENZYMES BP, A90
sodium sulfate / potassium sulfate / magnesium sulfatedrugId:2086 LAXATIVES BP, A90
Suprep (sodium sulfate / potassium sulfate / magnesium sulfate)drugId:2086 LAXATIVES BP, A90
sorafenibdrugId:1890 PA CHEMOTHERAPY BP, A90
sucralfate suspension ANTACIDS BP, A90
sunitinibdrugId:1917 PA CHEMOTHERAPY BP, A90
Sutent (sunitinib)drugId:1917 PA CHEMOTHERAPY BP, A90
Spiriva Handihaler (tiotropium inhalation powder)drugId:1708 BRONCHODILATORS BP, A90
Samsca (tolvaptan-Samsca)drugId:1728 PA VASOPRESSIN ANTAGONISTS BP, A90
Syprine (trientine capsule)drugId:1759 CHELATING AGENT BP, A90
Sabril (vigabatrin)drugId:1802 PA ANTICONVULSANTS BP, A90
saxagliptindrugId:1834 DIABETIC AGENTS BP, M90
saxagliptin / metformin extended-releasedrugId:2103 DIABETIC AGENTS BP, M90
Suboxone (buprenorphine / naloxone film)drugId:2050 PA > 90 days (> 24 mg/day and ≤ 32 mg/day) ALCOHOL AND DRUG CESSATION AGENT BP, PD
Suboxone (buprenorphine / naloxone film)drugId:2049 PA > 32 mg/day ALCOHOL AND DRUG CESSATION AGENT BP, PD
Suboxone (buprenorphine / naloxone film ≤ 24 mg/day)drugId:2085 ALCOHOL AND DRUG CESSATION AGENT BP, PD
StromectoldrugId:989 (ivermectin tablet)drugId:989 ANTIPARASITICS #
Solu-MedroldrugId:964 (methylprednisolone sodium succinate)drugId:964 GLUCOCORTICOIDS #
SandostatindrugId:1269 (octreotide injection)drugId:1269 ENDOCRINE/METABOLIC AGENTS #
sodium ferric gluconate complexdrugId:1865 HEMATINIC AGENT #
sodium phenylacetate / sodium benzoate ELECTROLYTES AND NUTRIENTS #
sulfamethoxazole / trimethoprim tabletdrugId:1907 ANTIBIOTICS #
Scenesse (afamelanotide)drugId:8115 PA DERMATOLOGICAL MB
Saphnelo (anifrolumab-fnia)drugId:8124 PA BIOLOGICAL MB
Simulect (basiliximab)drugId:2382 BIOLOGICAL MB
Sensorcaine (bupivacaine) ANESTHETICS MB
Sandimmune (cyclosporine injection)drugId:8711 IMMUNOMODULATOR MB
Soliris (eculizumab)drugId:589 PA BIOLOGICAL MB
Supartz (hyaluronate-Supartz)drugId:4809 PA HYALURONAN MB
Synojoynt (hyaluronate-Synojoynt)drugId:8196 PA HYALURONAN MB
Synvisc (hylan G-F20-Synvisc)drugId:4810 PA HYALURONAN MB
Synvisc-One (hylan G-F20-Synvisc-One)drugId:4811 PA HYALURONAN MB
Sarclisa (isatuximab-irfc)drugId:7395 PA CHEMOTHERAPY MB
Spinraza (nusinersen)drugId:6020 PA BIOLOGICAL MB
Signifor LAR (pasireotide injectable suspension)drugId:4912 PA ENDOCRINE/METABOLIC AGENTS MB
Syfovre (pegcetacoplan 150 mg/mL vial)drugId:8606 PA BIOLOGICAL MB
Sezaby (phenobarbital 100 mg vial)drugId:8725 BARBITURATES MB
Susvimo (ranibizumab) OPHTHALMIC PREPARATIONS MB
sacituzumab govitecan-hziydrugId:7397 PA CHEMOTHERAPY MB
samarium Sm 153 lexidronam CHEMOTHERAPY MB
sebelipase alfadrugId:5388 PA ENZYMES MB
siltuximabdrugId:4540 PA BIOLOGICAL MB
Sylvant (siltuximab)drugId:4540 PA BIOLOGICAL MB
sipuleucel-TdrugId:2288 PA CHEMOTHERAPY MB
sodium thiosulfatedrugId:8576 PA ANTIDOTES MB
streptozocindrugId:2700 CHEMOTHERAPY MB
sutimlimab-jomedrugId:8207 PA BIOLOGICAL MB
Sotradecol (tetradecyl sulfate injection)drugId:2495 PA CARDIOVASCULAR MB
Stelara (ustekinumab 130 mg/26 mL vial)drugId:8384 PA IMMUNOMODULATOR MB
saliva substitute ELECTROLYTES AND NUTRIENTS *
simple syrupdrugId:1854 COMPOUNDING AGENT *
sodium bicarbonate ELECTROLYTES AND NUTRIENTS *
sodium chloride for inhalation - Non-Drug Product ELECTROLYTES AND NUTRIENTS *
sodium chloride tablet ELECTROLYTES AND NUTRIENTS *
selenium sulfide DERMATOLOGICAL *, A90
sennosides syrupdrugId:1842 CONSTIPATION AGENTS *, A90
simethicone GASTROINTESTINAL AGENT *, A90
sodium phosphate GASTROINTESTINAL AGENT *, A90
sennosides tabletdrugId:8225 CONSTIPATION AGENTS *, M90
sodium fluoride ELECTROLYTES AND NUTRIENTS *, M90
salicylic aciddrugId:1827 DERMATOLOGICAL o, A90

Note: Any drug that does not appear on the List requires prior authorization.


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Last updated 06/24/24

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