MedicarePartD.guide

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2026 Blue MedicareRx Value (PDP) formulary (drug list)

Contract S5726, plan 013 · Kansas · 2,948 drugs on file · formulary ID 00026284. Each drug links to its cost in every CMS PDP Region 24 plan.

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190 drugs starting with D.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
DABIGATRAN ETEXILATE 110 mg Capsule4Non-Preferred Drug40%40%
  • QL 12 per 30 days
DABIGATRAN ETEXILATE 150 mg Capsule4Non-Preferred Drug40%40%
  • QL 6 per 30 days
DABIGATRAN ETEXILATE 75 mg Capsule4Non-Preferred Drug40%40%
  • QL 6 per 30 days
DALFAMPRIDINE 10 mg Tablet, Film Coated, Extended Release3Preferred Brand18%18%
  • PA
DANAZOL 100 mg Capsule4Non-Preferred Drug40%40%
  • PA
DANAZOL 200 mg Capsule4Non-Preferred Drug40%40%
  • PA
DANAZOL 50 mg Capsule4Non-Preferred Drug40%40%
  • PA
DANTROLENE SODIUM 100 mg Capsule4Non-Preferred Drug40%40%None
DANTROLENE SODIUM 25 mg Capsule4Non-Preferred Drug40%40%None
DANTROLENE SODIUM 50 mg Capsule4Non-Preferred Drug40%40%None
DANZITEN 71 mg TabletNilotinib5Specialty Tier25%N/A
  • PA
  • QL 112 per 28 days
DANZITEN 95 mg TabletNilotinib5Specialty Tier25%N/A
  • PA
  • QL 112 per 28 days
DAPAGLIFLOZIN 10 mg Tablet, Film Coated3Preferred Brand18%18%
  • QL 3 per 30 days
DAPAGLIFLOZIN 5 mg Tablet, Film Coated3Preferred Brand18%18%
  • QL 3 per 30 days
DAPSONE 100 mg Tablet3Preferred Brand18%18%None
DAPSONE 25 mg Tablet3Preferred Brand18%18%None
DAPTOMYCIN 500 mg/10mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug40%40%None
DARUNAVIR 600 mg Tablet, Film Coated4Non-Preferred Drug40%40%
  • QL 6 per 30 days
DARUNAVIR 800 mg Tablet, Film Coated4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DASATINIB 100 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
DASATINIB 140 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
DASATINIB 20 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
DASATINIB 50 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
DASATINIB 70 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
DASATINIB 80 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
DAURISMO 100 mg Tablet, Film CoatedGlasdegib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
DAURISMO 25 mg Tablet, Film CoatedGlasdegib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
DEBLITANE KitNorethindrone3Preferred Brand18%18%None
DEFERASIROX 180 mg Tablet4Non-Preferred Drug40%40%
  • PA
DEFERASIROX 360 mg Tablet, Film Coated4Non-Preferred Drug40%40%
  • PA
DEFERASIROX 90 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
DELSTRIGO 100/300/300 mg Tablet, Film CoatedDoravirine, Lamivudine, And Tenofovir Disoproxil Fumarate5Specialty Tier25%N/A
  • QL 3 per 30 days
DEPO-SUBQ PROVERA 104 mg/.65mL Injection, SuspensionMedroxyprogesterone Acetate3Preferred Brand18%18%None
DESCOVY 120/15 mg TabletEmtricitabine And Tenofovir Alafenamide5Specialty Tier25%N/A
  • QL 3 per 30 days
DESCOVY 200/25 mg TabletEmtricitabine And Tenofovir Alafenamide5Specialty Tier25%N/A
  • QL 3 per 30 days
DESIPRAMINE HYDROCHLORIDE 10 mg Tablet4Non-Preferred Drug40%40%None
DESIPRAMINE HYDROCHLORIDE 100 mg Tablet4Non-Preferred Drug40%40%None
DESIPRAMINE HYDROCHLORIDE 150 mg Tablet4Non-Preferred Drug40%40%None
DESIPRAMINE HYDROCHLORIDE 25 mg Tablet4Non-Preferred Drug40%40%None
DESIPRAMINE HYDROCHLORIDE 50 mg Tablet4Non-Preferred Drug40%40%None
DESIPRAMINE HYDROCHLORIDE 75 mg Tablet4Non-Preferred Drug40%40%None
DESMOPRESSIN ACETATE .1 mg Tablet3Preferred Brand18%18%None
DESMOPRESSIN ACETATE .1 mg/mL Solution4Non-Preferred Drug40%40%None
DESMOPRESSIN ACETATE .2 mg Tablet3Preferred Brand18%18%None
DESVENLAFAXINE 100 mg Tablet, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DESVENLAFAXINE 25 mg Tablet, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DESVENLAFAXINE 50 mg Tablet, Film Coated, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DEXAMETHASONE .5 mg Tablet4Non-Preferred Drug40%40%None
DEXAMETHASONE .5 mg/5mL Solution4Non-Preferred Drug40%40%None
DEXAMETHASONE .75 mg Tablet4Non-Preferred Drug40%40%None
DEXAMETHASONE 1 mg Tablet4Non-Preferred Drug40%40%None
DEXAMETHASONE 2 mg Tablet4Non-Preferred Drug40%40%None
DEXAMETHASONE 4 mg Tablet4Non-Preferred Drug40%40%None
DEXAMETHASONE 6 mg Tablet4Non-Preferred Drug40%40%None
DEXAMETHASONE SODIUM PHOSPHATE 1 mg/mL Solution/ Drops3Preferred Brand18%18%None
DEXMETHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet4Non-Preferred Drug40%40%
  • PA
  • QL 6 per 30 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 2.5 mg Tablet4Non-Preferred Drug40%40%
  • PA
  • QL 6 per 30 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 5 mg Tablet4Non-Preferred Drug40%40%
  • PA
  • QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 7.5/7.5/7.5/7.5 mg Capsule, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Capsule, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Capsule, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 6.25/6.25/6.25/6.25 mg Capsule, Extended Release4Non-Preferred Drug40%40%
  • QL 3 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Tablet3Preferred Brand18%18%
  • QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.875/1.875/1.875/1.875 mg Tablet3Preferred Brand18%18%
  • QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 2.5/2.5/2.5/2.5 mg Tablet3Preferred Brand18%18%
  • QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 3.125/3.125/3.125/3.125 mg Tablet3Preferred Brand18%18%
  • QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Tablet3Preferred Brand18%18%
  • QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 5/5/5/5 mg Tablet3Preferred Brand18%18%
  • QL 9 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 7.5/7.5/7.5/7.5 mg Tablet3Preferred Brand18%18%
  • QL 6 per 30 days
DEXTROAMPHETAMINE SULFATE 10 mg Tablet4Non-Preferred Drug40%40%
  • QL 18 per 30 days
DEXTROAMPHETAMINE SULFATE 5 mg Tablet4Non-Preferred Drug40%40%
  • QL 9 per 30 days
DEXTROSE 100 g/1000mL Injection, SolutionDextrose Monohydrate4Non-Preferred Drug40%40%None
DEXTROSE 50 mg/mL Injection, SolutionDextrose Monohydrate4Non-Preferred Drug40%40%None
DEXTROSE AND SODIUM CHLORIDE 2.5/450 g/100mL/mg/100mL Injection, Solution4Non-Preferred Drug40%40%None
DEXTROSE AND SODIUM CHLORIDE 5/.2 g/100mL Injection, Solution4Non-Preferred Drug40%40%None
DEXTROSE AND SODIUM CHLORIDE 5/.9 g/100mL Injection, SolutionDextrose Monohydrate And Sodium Chloride4Non-Preferred Drug40%40%None
DIACOMIT 250 mg CapsuleStiripentol5Specialty Tier25%N/ANone
DIACOMIT 250 mg Powder, For SuspensionStiripentol5Specialty Tier25%N/ANone
DIACOMIT 500 mg CapsuleStiripentol5Specialty Tier25%N/ANone
DIACOMIT 500 mg Powder, For SuspensionStiripentol5Specialty Tier25%N/ANone
DIAZEPAM 10 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 12 per 30 days
DIAZEPAM 2 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 12 per 30 days
DIAZEPAM 2.5 mg/.5mL Gel4Non-Preferred Drug40%40%
  • QL 5 per 30 days
DIAZEPAM 5 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 12 per 30 days
DIAZEPAM 5 mg/5mL Solution4Non-Preferred Drug40%40%
  • PA
  • QL 12 per 30 days
DIAZEPAM INTENSOL 5 mg/mL Solution, Concentrate4Non-Preferred Drug40%40%
  • PA
  • QL 24 per 30 days
DIAZOXIDE 50 mg/mL Suspension4Non-Preferred Drug40%40%None
DICLOFENAC POTASSIUM 50 mg Tablet, Film Coated4Non-Preferred Drug40%40%
  • QL 12 per 30 days
DICLOFENAC SODIUM 1 mg/mL Solution/ Drops2Generic$2.00$6.00None
DICLOFENAC SODIUM 100 mg Tablet, Film Coated, Extended Release2Generic$2.00$6.00
  • QL 6 per 30 days
DICLOFENAC SODIUM 16.05 mg/mL Solution3Preferred Brand18%18%
  • PA
DICLOFENAC SODIUM 25 mg Tablet, Delayed Release3Preferred Brand18%18%
  • QL 24 per 30 days
DICLOFENAC SODIUM 50 mg Tablet, Delayed Release2Generic$2.00$6.00
  • QL 12 per 30 days
DICLOFENAC SODIUM 75 mg Tablet, Delayed Release2Generic$2.00$6.00
  • QL 6 per 30 days
DICLOXACILLIN SODIUM 250 mg Capsule3Preferred Brand18%18%None
DICLOXACILLIN SODIUM 500 mg Capsule3Preferred Brand18%18%None
DICYCLOMINE 20 mg TabletDicyclomine Hydrochloride4Non-Preferred Drug40%40%
  • PA
DICYCLOMINE HYDROCHLORIDE 10 mg Capsule4Non-Preferred Drug40%40%
  • PA
DICYCLOMINE HYDROCHLORIDE 10 mg/5mL Solution4Non-Preferred Drug40%40%
  • PA
DIFICID 200 mg Tablet, Film CoatedFidaxomicin5Specialty Tier25%N/A
  • QL 2 per 10 days
DIFICID 200 mg/5mL Granule, For SuspensionFidaxomicin5Specialty Tier25%N/A
  • QL 136 per 10 days
DIGOXIN .05 mg/mL Solution4Non-Preferred Drug40%40%
  • QL 15 per 30 days
DIGOXIN 125 ug Tablet2Generic$2.00$6.00
  • QL 3 per 30 days
DIGOXIN 250 ug Tablet2Generic$2.00$6.00
  • QL 3 per 30 days
DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered5Specialty Tier25%N/A
  • PA
  • QL 8 per 28 days
DILANTIN 30 mg Capsule, Extended ReleaseExtended Phenytoin Sodium4Non-Preferred Drug40%40%None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 120 mg Tablet, Film Coated2Generic$2.00$6.00None
DILTIAZEM HYDROCHLORIDE 180 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 180 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 240 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 240 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 30 mg Tablet, Film Coated2Generic$2.00$6.00None
DILTIAZEM HYDROCHLORIDE 300 mg Capsule, Extended Release3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE 60 mg Tablet, Film Coated2Generic$2.00$6.00None
DILTIAZEM HYDROCHLORIDE 90 mg Tablet, Film Coated2Generic$2.00$6.00None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE 360 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand18%18%None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE 420 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand18%18%None
DIMETHYL FUMARATE 120 mg Capsule, Delayed Release4Non-Preferred Drug40%40%
  • PA
  • QL 6 per 30 days
DIMETHYL FUMARATE 240 mg Capsule, Delayed Release4Non-Preferred Drug40%40%
  • PA
  • QL 6 per 30 days
DIMETHYL FUMARATE Kit4Non-Preferred Drug40%40%
  • PA
  • QL 6 per 30 days
DIPHENOXYLATE HYDROCHLORIDE AND ATROPINE SULFATE 2.5/.025 mg Tablet4Non-Preferred Drug40%40%
  • PA
DISULFIRAM 250 mg Tablet4Non-Preferred Drug40%40%None
DISULFIRAM 500 mg Tablet4Non-Preferred Drug40%40%None
DIVALPROEX SODIUM 125 mg Capsule, Coated Pellets4Non-Preferred Drug40%40%None
DIVALPROEX SODIUM 125 mg Tablet, Delayed Release2Generic$2.00$6.00None
DIVALPROEX SODIUM 250 mg Tablet, Delayed Release2Generic$2.00$6.00None
DIVALPROEX SODIUM 250 mg Tablet, Extended Release4Non-Preferred Drug40%40%None
DIVALPROEX SODIUM 500 mg Tablet, Delayed Release2Generic$2.00$6.00None
DIVALPROEX SODIUM 500 mg Tablet, Extended Release4Non-Preferred Drug40%40%None
DOFETILIDE .125 mg Capsule4Non-Preferred Drug40%40%None
DOFETILIDE .25 mg Capsule4Non-Preferred Drug40%40%None
DOFETILIDE .5 mg Capsule4Non-Preferred Drug40%40%None
DONEPEZIL HYDROCHLORIDE 10 mg Tablet, Film Coated2Generic$2.00$6.00None
DONEPEZIL HYDROCHLORIDE 10 mg Tablet, Orally Disintegrating2Generic$2.00$6.00None
DONEPEZIL HYDROCHLORIDE 5 mg Tablet, Film Coated2Generic$2.00$6.00None
DONEPEZIL HYDROCHLORIDE 5 mg Tablet, Orally Disintegrating2Generic$2.00$6.00None
DORZOLAMIDE HCL 20 mg/mL Solution/ Drops2Generic$2.00$6.00None
DORZOLAMIDE HYDROCHLORIDE AND TIMOLOL MALEATE 20/5 mg/mL Solution2Generic$2.00$6.00None
DOTTI .025 mg/d Patch, Extended ReleaseEstradiol4Non-Preferred Drug40%40%None
DOTTI .0375 mg/d Patch, Extended ReleaseEstradiol4Non-Preferred Drug40%40%None
DOTTI .05 mg/d Patch, Extended ReleaseEstradiol4Non-Preferred Drug40%40%None
DOTTI .075 mg/d Patch, Extended ReleaseEstradiol4Non-Preferred Drug40%40%None
DOTTI .1 mg/d Patch, Extended ReleaseEstradiol4Non-Preferred Drug40%40%None
DOVATO 50/300 mg Tablet, Film CoatedDolutegravir Sodium And Lamivudine5Specialty Tier25%N/A
  • QL 3 per 30 days
DOXAZOSIN 1 mg Tablet2Generic$2.00$6.00
  • QL 6 per 30 days
DOXAZOSIN 2 mg Tablet2Generic$2.00$6.00
  • QL 6 per 30 days
DOXAZOSIN 4 mg Tablet2Generic$2.00$6.00
  • QL 6 per 30 days
DOXAZOSIN 8 mg Tablet2Generic$2.00$6.00
  • QL 6 per 30 days
DOXEPIN HYDROCHLORIDE 10 mg Capsule4Non-Preferred Drug40%40%None
DOXEPIN HYDROCHLORIDE 10 mg/mL Solution4Non-Preferred Drug40%40%None
DOXEPIN HYDROCHLORIDE 100 mg Capsule4Non-Preferred Drug40%40%None
DOXEPIN HYDROCHLORIDE 25 mg Capsule4Non-Preferred Drug40%40%None
DOXEPIN HYDROCHLORIDE 50 mg Capsule4Non-Preferred Drug40%40%None
DOXEPIN HYDROCHLORIDE 75 mg Capsule4Non-Preferred Drug40%40%None
DOXY 100 100 mg/10mL Injection, Powder, Lyophilized, For SolutionDoxycycline4Non-Preferred Drug40%40%None
DOXYCYCLINE 100 mg Capsule3Preferred Brand18%18%None
DOXYCYCLINE 100 mg Capsule4Non-Preferred Drug40%40%None
DOXYCYCLINE 100 mg Tablet3Preferred Brand18%18%None
DOXYCYCLINE 100 mg/10mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug40%40%None
DOXYCYCLINE 50 mg Capsule4Non-Preferred Drug40%40%None
DOXYCYCLINE 50 mg Tablet3Preferred Brand18%18%None
DOXYCYCLINE 75 mg Tablet3Preferred Brand18%18%None
DOXYCYCLINE HYCLATE 20 mg Tablet, Film Coated3Preferred Brand18%18%None
DOXYCYCLINE HYCLATE 50 mg Capsule3Preferred Brand18%18%None
DRIZALMA SPRINKLE 20 mg Capsule, Delayed ReleaseDuloxetine4Non-Preferred Drug40%40%
  • QL 6 per 30 days
DRIZALMA SPRINKLE 30 mg Capsule, Delayed ReleaseDuloxetine4Non-Preferred Drug40%40%
  • QL 9 per 30 days
DRIZALMA SPRINKLE 40 mg Capsule, Delayed ReleaseDuloxetine4Non-Preferred Drug40%40%
  • QL 6 per 30 days
DRIZALMA SPRINKLE 60 mg Capsule, Delayed ReleaseDuloxetine4Non-Preferred Drug40%40%
  • QL 6 per 30 days
DRONABINOL 10 mg Capsule4Non-Preferred Drug40%40%
  • PA
DRONABINOL 2.5 mg Capsule4Non-Preferred Drug40%40%
  • PA
DRONABINOL 5 mg Capsule4Non-Preferred Drug40%40%
  • PA
DROSPIRENONE AND ETHINYL ESTRADIOL Kit4Non-Preferred Drug40%40%None
DROSPIRENONE AND ETHINYL ESTRADIOL Kit4Non-Preferred Drug40%40%None
DROXIDOPA 100 mg Capsule4Non-Preferred Drug40%40%
  • PA
DROXIDOPA 200 mg Capsule4Non-Preferred Drug40%40%
  • PA
DROXIDOPA 300 mg Capsule4Non-Preferred Drug40%40%
  • PA
DUAVEE .45/20 mg Tablet, Film CoatedConjugated Estrogens/Bazedoxifene4Non-Preferred Drug40%40%None
DULERA 100/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate3Preferred Brand18%18%
  • QL 39 per 30 days
DULERA 200/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate3Preferred Brand18%18%
  • QL 39 per 30 days
DULERA 50/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate3Preferred Brand18%18%
  • QL 39 per 30 days
DULOXETINE 20 mg Capsule, Delayed Release3Preferred Brand18%18%
  • QL 6 per 30 days
DULOXETINE 30 mg Capsule, Delayed Release3Preferred Brand18%18%
  • QL 9 per 30 days
DULOXETINE 60 mg Capsule, Delayed Release3Preferred Brand18%18%
  • QL 6 per 30 days
DUPIXENT 200 mg/1.14mL Injection, SolutionDupilumab5Specialty Tier25%N/A
  • PA
  • QL 3.42 per 28 days
DUPIXENT 200 mg/1.14mL Injection, SolutionDupilumab5Specialty Tier25%N/A
  • PA
  • QL 3.42 per 28 days
DUPIXENT 300 mg/2mL Injection, SolutionDupilumab5Specialty Tier25%N/A
  • PA
  • QL 8 per 28 days
DUPIXENT 300 mg/2mL Injection, SolutionDupilumab5Specialty Tier25%N/A
  • PA
  • QL 8 per 28 days
DUTASTERIDE .5 mg Capsule, Liquid Filled4Non-Preferred Drug40%40%
  • QL 3 per 30 days

PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.