2026 AARP Medicare Rx Preferred from UHC (PDP) formulary (drug list)

Contract S5921, plan 406 · Montana · 3,518 drugs on file · formulary ID 00026000. Each drug links to its cost in every CMS PDP Region 25 plan.

240 drugs starting with D.

Drug name	Tier	30-day preferred pharmacy	90-day mail order	Usage management
DABIGATRAN ETEXILATE 110 mg Capsule	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DABIGATRAN ETEXILATE 150 mg Capsule	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DABIGATRAN ETEXILATE 75 mg Capsule	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DALFAMPRIDINE 10 mg Tablet, Film Coated, Extended Release	3Preferred Brand	18%	18%	QL 6 per 30 days
DANAZOL 100 mg Capsule	4Non-Preferred Drug	34%	N/A	None
DANAZOL 200 mg Capsule	4Non-Preferred Drug	34%	N/A	None
DANAZOL 50 mg Capsule	4Non-Preferred Drug	34%	N/A	None
DANTROLENE SODIUM 100 mg Capsule	4Non-Preferred Drug	34%	N/A	None
DANTROLENE SODIUM 25 mg Capsule	4Non-Preferred Drug	34%	N/A	None
DANTROLENE SODIUM 50 mg Capsule	4Non-Preferred Drug	34%	N/A	None
DANZITEN 71 mg TabletNilotinib	5Specialty Tier	31%	N/A	PA QL 12 per 30 days
DANZITEN 95 mg TabletNilotinib	5Specialty Tier	31%	N/A	PA QL 12 per 30 days
DAPAGLIFLOZIN 10 mg Tablet, Film Coated	3Preferred Brand	18%	18%	QL 3 per 30 days
DAPAGLIFLOZIN 5 mg Tablet, Film Coated	3Preferred Brand	18%	18%	QL 3 per 30 days
DAPSONE 100 mg Tablet	3Preferred Brand	18%	18%	None
DAPSONE 25 mg Tablet	3Preferred Brand	18%	18%	None
DAPTOMYCIN 500 mg/10mL Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	34%	N/A	None
DARUNAVIR 600 mg Tablet, Film Coated	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DARUNAVIR 800 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	QL 3 per 30 days
DASATINIB 100 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	PA QL 3 per 30 days
DASATINIB 140 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	PA QL 3 per 30 days
DASATINIB 20 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	PA QL 9 per 30 days
DASATINIB 50 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	PA QL 9 per 30 days
DASATINIB 70 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	PA QL 3 per 30 days
DASATINIB 80 mg Tablet, Film Coated	5Specialty Tier	31%	N/A	PA QL 6 per 30 days
DAURISMO 100 mg Tablet, Film CoatedGlasdegib	5Specialty Tier	31%	N/A	PA QL 3 per 30 days
DAURISMO 25 mg Tablet, Film CoatedGlasdegib	5Specialty Tier	31%	N/A	PA QL 6 per 30 days
DEBLITANE KitNorethindrone	3Preferred Brand	18%	18%	None
DEFERASIROX 125 mg Tablet, For Suspension	4Non-Preferred Drug	34%	N/A	PA
DEFERASIROX 180 mg Tablet	3Preferred Brand	18%	18%	PA
DEFERASIROX 250 mg Tablet, For Suspension	4Non-Preferred Drug	34%	N/A	PA
DEFERASIROX 360 mg Tablet, Film Coated	3Preferred Brand	18%	18%	PA
DEFERASIROX 500 mg Tablet, For Suspension	4Non-Preferred Drug	34%	N/A	PA
DEFERASIROX 90 mg Tablet, Film Coated	3Preferred Brand	18%	18%	PA
DELSTRIGO 100/300/300 mg Tablet, Film CoatedDoravirine, Lamivudine, And Tenofovir Disoproxil Fumarate	5Specialty Tier	31%	N/A	QL 3 per 30 days
DEMECLOCYCLINE HYDROCHLORIDE 150 mg TabletDemeclocycline	4Non-Preferred Drug	34%	N/A	None
DEMECLOCYCLINE HYDROCHLORIDE 300 mg TabletDemeclocycline	4Non-Preferred Drug	34%	N/A	None
DEPO-ESTRADIOL 5 mg/mL InjectionEstradiol Cypionate	4Non-Preferred Drug	34%	N/A	None
DEPO-SUBQ PROVERA 104 mg/.65mL Injection, SuspensionMedroxyprogesterone Acetate	3Preferred Brand	18%	18%	None
DESCOVY 120/15 mg TabletEmtricitabine And Tenofovir Alafenamide	5Specialty Tier	31%	N/A	QL 3 per 30 days
DESCOVY 200/25 mg TabletEmtricitabine And Tenofovir Alafenamide	5Specialty Tier	31%	N/A	QL 3 per 30 days
DESIPRAMINE HYDROCHLORIDE 10 mg Tablet	4Non-Preferred Drug	34%	N/A	PA
DESIPRAMINE HYDROCHLORIDE 100 mg Tablet	4Non-Preferred Drug	34%	N/A	PA
DESIPRAMINE HYDROCHLORIDE 150 mg Tablet	4Non-Preferred Drug	34%	N/A	PA
DESIPRAMINE HYDROCHLORIDE 25 mg Tablet	4Non-Preferred Drug	34%	N/A	PA
DESIPRAMINE HYDROCHLORIDE 50 mg Tablet	4Non-Preferred Drug	34%	N/A	PA
DESIPRAMINE HYDROCHLORIDE 75 mg Tablet	4Non-Preferred Drug	34%	N/A	PA
DESLORATADINE 5 mg Tablet, Film Coated	3Preferred Brand	18%	18%	None
DESMOPRESSIN ACETATE .1 mg Tablet	3Preferred Brand	18%	18%	None
DESMOPRESSIN ACETATE .1 mg/mL Solution	4Non-Preferred Drug	34%	N/A	None
DESMOPRESSIN ACETATE .2 mg Tablet	3Preferred Brand	18%	18%	None
DESONIDE .5 mg/g Ointment	4Non-Preferred Drug	34%	N/A	QL 12 per 30 days
DESOXIMETASONE 2.5 mg/g Cream	4Non-Preferred Drug	34%	N/A	QL 1 per 30 days
DESVENLAFAXINE 100 mg Tablet, Extended Release	3Preferred Brand	18%	18%	QL 12 per 30 days
DESVENLAFAXINE 25 mg Tablet, Extended Release	3Preferred Brand	18%	18%	QL 3 per 30 days
DESVENLAFAXINE 50 mg Tablet, Film Coated, Extended Release	3Preferred Brand	18%	18%	QL 3 per 30 days
DEXAMETHASONE .5 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE .5 mg/5mL Solution	2Generic	$10.00	$0.00	None
DEXAMETHASONE .75 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE 1 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE 1.5 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE 2 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE 4 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE 6 mg Tablet	2Generic	$10.00	$0.00	None
DEXAMETHASONE SODIUM PHOSPHATE 1 mg/mL Solution/ Drops	2Generic	$10.00	$0.00	None
DEXLANSOPRAZOLE 60 mg Capsule, Delayed Release	4Non-Preferred Drug	34%	N/A	QL 3 per 30 days
DEXLANSOPRAZOLE DELAYED RELEASE 30 mg Capsule, Delayed ReleaseDexlansoprazole	4Non-Preferred Drug	34%	N/A	QL 3 per 30 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 10 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 2.5 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 20 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE 35 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE 5 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 15 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 25 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 30 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 40 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride	4Non-Preferred Drug	34%	N/A	None
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 5 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride	4Non-Preferred Drug	34%	N/A	None
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 7.5/7.5/7.5/7.5 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 6.25/6.25/6.25/6.25 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.875/1.875/1.875/1.875 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 2.5/2.5/2.5/2.5 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 3.125/3.125/3.125/3.125 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 5/5/5/5 mg Tablet	3Preferred Brand	18%	18%	QL 9 per 30 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 7.5/7.5/7.5/7.5 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
DEXTROAMPHETAMINE SULFATE 10 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 18 per 30 days
DEXTROAMPHETAMINE SULFATE 10 mg Tablet	4Non-Preferred Drug	34%	N/A	QL 18 per 30 days
DEXTROAMPHETAMINE SULFATE 15 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 12 per 30 days
DEXTROAMPHETAMINE SULFATE 15 mg Tablet	4Non-Preferred Drug	34%	N/A	QL 9 per 30 days
DEXTROAMPHETAMINE SULFATE 20 mg Tablet	4Non-Preferred Drug	34%	N/A	QL 9 per 30 days
DEXTROAMPHETAMINE SULFATE 30 mg Tablet	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DEXTROAMPHETAMINE SULFATE 5 mg Capsule, Extended Release	4Non-Preferred Drug	34%	N/A	QL 9 per 30 days
DEXTROAMPHETAMINE SULFATE 5 mg Tablet	4Non-Preferred Drug	34%	N/A	QL 18 per 30 days
DEXTROSE 100 g/1000mL Injection, SolutionDextrose Monohydrate	4Non-Preferred Drug	34%	N/A	None
DEXTROSE 50 mg/mL Injection, SolutionDextrose Monohydrate	4Non-Preferred Drug	34%	N/A	None
DEXTROSE AND SODIUM CHLORIDE 10/.2 g/100mL Injection, Solution	4Non-Preferred Drug	34%	N/A	None
DEXTROSE AND SODIUM CHLORIDE 10/.45 g/100mL Injection, Solution	4Non-Preferred Drug	34%	N/A	None
DEXTROSE AND SODIUM CHLORIDE 2.5/450 g/100mL/mg/100mL Injection, Solution	4Non-Preferred Drug	34%	N/A	None
DEXTROSE AND SODIUM CHLORIDE 5/.2 g/100mL Injection, Solution	4Non-Preferred Drug	34%	N/A	None
DEXTROSE AND SODIUM CHLORIDE 5/.9 g/100mL Injection, SolutionDextrose Monohydrate And Sodium Chloride	4Non-Preferred Drug	34%	N/A	None
DIACOMIT 250 mg CapsuleStiripentol	5Specialty Tier	31%	N/A	QL 36 per 30 days
DIACOMIT 250 mg Powder, For SuspensionStiripentol	5Specialty Tier	31%	N/A	QL 36 per 30 days
DIACOMIT 500 mg CapsuleStiripentol	5Specialty Tier	31%	N/A	QL 18 per 30 days
DIACOMIT 500 mg Powder, For SuspensionStiripentol	5Specialty Tier	31%	N/A	QL 18 per 30 days
DIAZEPAM 10 mg Tablet	2Generic	$10.00	$0.00	PA QL 12 per 30 days
DIAZEPAM 2 mg Tablet	2Generic	$10.00	$0.00	PA QL 12 per 30 days
DIAZEPAM 2.5 mg/.5mL Gel	4Non-Preferred Drug	34%	N/A	QL 5 per 30 days
DIAZEPAM 5 mg Tablet	2Generic	$10.00	$0.00	PA QL 12 per 30 days
DIAZEPAM 5 mg/5mL Solution	4Non-Preferred Drug	34%	N/A	PA
DIAZEPAM INTENSOL 5 mg/mL Solution, Concentrate	4Non-Preferred Drug	34%	N/A	PA QL 24 per 30 days
DIAZOXIDE 50 mg/mL Suspension	4Non-Preferred Drug	34%	N/A	None
DICLOFENAC POTASSIUM 50 mg Tablet, Film Coated	2Generic	$10.00	$0.00	None
DICLOFENAC SODIUM 1 mg/mL Solution/ Drops	2Generic	$10.00	$0.00	None
DICLOFENAC SODIUM 100 mg Tablet, Film Coated, Extended Release	2Generic	$10.00	$0.00	None
DICLOFENAC SODIUM 16.05 mg/mL Solution	3Preferred Brand	18%	18%	PA
DICLOFENAC SODIUM 25 mg Tablet, Delayed Release	2Generic	$10.00	$0.00	None
DICLOFENAC SODIUM 30 mg/g Gel	4Non-Preferred Drug	34%	N/A	PA QL 1 per 30 days
DICLOFENAC SODIUM 50 mg Tablet, Delayed Release	2Generic	$10.00	$0.00	None
DICLOFENAC SODIUM 75 mg Tablet, Delayed Release	2Generic	$10.00	$0.00	None
DICLOXACILLIN SODIUM 250 mg Capsule	2Generic	$10.00	$0.00	None
DICLOXACILLIN SODIUM 500 mg Capsule	2Generic	$10.00	$0.00	None
DICYCLOMINE 20 mg TabletDicyclomine Hydrochloride	4Non-Preferred Drug	34%	N/A	PA
DICYCLOMINE HYDROCHLORIDE 10 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DICYCLOMINE HYDROCHLORIDE 10 mg/5mL Solution	4Non-Preferred Drug	34%	N/A	PA
DIFICID 200 mg Tablet, Film CoatedFidaxomicin	5Specialty Tier	31%	N/A	None
DIFLUNISAL 500 mg Tablet, Film Coated	3Preferred Brand	18%	18%	None
DIGOXIN .05 mg/mL Solution	4Non-Preferred Drug	34%	N/A	None
DIGOXIN .0625 mg Tablet	4Non-Preferred Drug	34%	N/A	None
DIGOXIN 125 ug Tablet	2Generic	$10.00	$0.00	None
DIGOXIN 250 ug Tablet	2Generic	$10.00	$0.00	None
DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered	4Non-Preferred Drug	34%	N/A	QL 16 per 28 days
DILANTIN 100 mg Capsule, Extended ReleaseExtended Phenytoin Sodium	3Preferred Brand	18%	18%	None
DILANTIN 30 mg Capsule, Extended ReleaseExtended Phenytoin Sodium	3Preferred Brand	18%	18%	None
DILANTIN INFATABS 50 mg Tablet, ChewablePhenytoin	3Preferred Brand	18%	18%	None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 120 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 120 mg Tablet, Film Coated	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 180 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 180 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 180 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 240 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 240 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 240 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 30 mg Tablet, Film Coated	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 300 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 300 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 360 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 420 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 60 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 60 mg Tablet, Film Coated	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 90 mg Capsule, Extended Release	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE 90 mg Tablet, Film Coated	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE 360 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$10.00	$0.00	None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE 420 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$10.00	$0.00	None
DIMETHYL FUMARATE 120 mg Capsule, Delayed Release	4Non-Preferred Drug	34%	N/A	QL 56 per 28 days
DIMETHYL FUMARATE 240 mg Capsule, Delayed Release	4Non-Preferred Drug	34%	N/A	QL 6 per 30 days
DIMETHYL FUMARATE Kit	4Non-Preferred Drug	34%	N/A	QL 12 per 365 days
DIPHENOXYLATE HYDROCHLORIDE AND ATROPINE SULFATE 2.5/.025 mg Tablet	3Preferred Brand	18%	18%	PA
DISULFIRAM 250 mg Tablet	4Non-Preferred Drug	34%	N/A	None
DISULFIRAM 500 mg Tablet	4Non-Preferred Drug	34%	N/A	None
DIVALPROEX SODIUM 125 mg Capsule, Coated Pellets	2Generic	$10.00	$0.00	None
DIVALPROEX SODIUM 125 mg Tablet, Delayed Release	2Generic	$10.00	$0.00	None
DIVALPROEX SODIUM 250 mg Tablet, Delayed Release	2Generic	$10.00	$0.00	None
DIVALPROEX SODIUM 250 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DIVALPROEX SODIUM 500 mg Tablet, Delayed Release	2Generic	$10.00	$0.00	None
DIVALPROEX SODIUM 500 mg Tablet, Extended Release	2Generic	$10.00	$0.00	None
DOFETILIDE .125 mg Capsule	3Preferred Brand	18%	18%	QL 18 per 30 days
DOFETILIDE .25 mg Capsule	3Preferred Brand	18%	18%	QL 6 per 30 days
DOFETILIDE .5 mg Capsule	3Preferred Brand	18%	18%	QL 6 per 30 days
DOLISHALE 90/20 ug TabletLevonorgestrel And Ethinyl Estradiol	3Preferred Brand	18%	18%	None
DONEPEZIL HYDROCHLORIDE 10 mg Tablet, Film Coated	1Preferred Generic	$5.00	$0.00	QL 6 per 30 days
DONEPEZIL HYDROCHLORIDE 10 mg Tablet, Orally Disintegrating	2Generic	$10.00	$0.00	QL 6 per 30 days
DONEPEZIL HYDROCHLORIDE 23 mg Tablet, Film Coated	2Generic	$10.00	$0.00	QL 3 per 30 days
DONEPEZIL HYDROCHLORIDE 5 mg Tablet, Film Coated	1Preferred Generic	$5.00	$0.00	QL 3 per 30 days
DONEPEZIL HYDROCHLORIDE 5 mg Tablet, Orally Disintegrating	2Generic	$10.00	$0.00	QL 3 per 30 days
DOPTELET 20 mg Tablet, Film CoatedAvatrombopag Maleate	5Specialty Tier	31%	N/A	PA QL 9 per 30 days
DOPTELET 20 mg Tablet, Film CoatedAvatrombopag Maleate	5Specialty Tier	31%	N/A	PA QL 9 per 30 days
DOPTELET 20 mg Tablet, Film CoatedAvatrombopag Maleate	5Specialty Tier	31%	N/A	PA QL 9 per 30 days
DOPTELET SPRINKLE 10 mg GranuleAvatrombopag	5Specialty Tier	31%	N/A	PA QL 6 per 30 days
DORZOLAMIDE HCL 20 mg/mL Solution/ Drops	2Generic	$10.00	$0.00	None
DORZOLAMIDE HYDROCHLORIDE AND TIMOLOL MALEATE 20/5 mg/mL Solution	2Generic	$10.00	$0.00	None
DORZOLAMIDE HYDROCHLORIDE AND TIMOLOL MALEATE PRESERVATIVE FREE 20/5 mg/mL Solution/ Drops	4Non-Preferred Drug	34%	N/A	None
DOVATO 50/300 mg Tablet, Film CoatedDolutegravir Sodium And Lamivudine	5Specialty Tier	31%	N/A	QL 3 per 30 days
DOXAZOSIN 1 mg Tablet	2Generic	$10.00	$0.00	None
DOXAZOSIN 2 mg Tablet	2Generic	$10.00	$0.00	None
DOXAZOSIN 4 mg Tablet	2Generic	$10.00	$0.00	None
DOXAZOSIN 8 mg Tablet	2Generic	$10.00	$0.00	None
DOXEPIN HYDROCHLORIDE 10 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXEPIN HYDROCHLORIDE 10 mg/mL Solution	4Non-Preferred Drug	34%	N/A	PA
DOXEPIN HYDROCHLORIDE 100 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXEPIN HYDROCHLORIDE 25 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXEPIN HYDROCHLORIDE 50 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXEPIN HYDROCHLORIDE 75 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXERCALCIFEROL .5 ug Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXERCALCIFEROL 1 ug Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXERCALCIFEROL 2.5 ug Capsule	4Non-Preferred Drug	34%	N/A	PA
DOXY 100 100 mg/10mL Injection, Powder, Lyophilized, For SolutionDoxycycline	4Non-Preferred Drug	34%	N/A	None
DOXYCYCLINE 100 mg Capsule	3Preferred Brand	18%	18%	None
DOXYCYCLINE 100 mg Capsule	3Preferred Brand	18%	18%	None
DOXYCYCLINE 100 mg Tablet	3Preferred Brand	18%	18%	None
DOXYCYCLINE 100 mg/10mL Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	34%	N/A	None
DOXYCYCLINE 25 mg/5mL For Suspension	4Non-Preferred Drug	34%	N/A	None
DOXYCYCLINE 50 mg Capsule	3Preferred Brand	18%	18%	None
DOXYCYCLINE 50 mg Tablet	3Preferred Brand	18%	18%	None
DOXYCYCLINE 75 mg Tablet	3Preferred Brand	18%	18%	None
DOXYCYCLINE HYCLATE 20 mg Tablet, Film Coated	3Preferred Brand	18%	18%	None
DOXYCYCLINE HYCLATE 50 mg Capsule	3Preferred Brand	18%	18%	None
DRIZALMA SPRINKLE 20 mg Capsule, Delayed ReleaseDuloxetine	4Non-Preferred Drug	34%	N/A	ST QL 6 per 30 days
DRIZALMA SPRINKLE 30 mg Capsule, Delayed ReleaseDuloxetine	4Non-Preferred Drug	34%	N/A	ST QL 9 per 30 days
DRIZALMA SPRINKLE 40 mg Capsule, Delayed ReleaseDuloxetine	4Non-Preferred Drug	34%	N/A	ST QL 6 per 30 days
DRIZALMA SPRINKLE 60 mg Capsule, Delayed ReleaseDuloxetine	4Non-Preferred Drug	34%	N/A	ST QL 6 per 30 days
DRONABINOL 10 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DRONABINOL 2.5 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DRONABINOL 5 mg Capsule	4Non-Preferred Drug	34%	N/A	PA
DROSPIRENONE AND ETHINYL ESTRADIOL Kit	3Preferred Brand	18%	18%	None
DROSPIRENONE AND ETHINYL ESTRADIOL Kit	3Preferred Brand	18%	18%	None
DROXIA 200 mg CapsuleHydroxyurea	3Preferred Brand	18%	18%	None
DROXIA 300 mg CapsuleHydroxyurea	3Preferred Brand	18%	18%	None
DROXIA 400 mg CapsuleHydroxyurea	3Preferred Brand	18%	18%	None
DROXIDOPA 100 mg Capsule	4Non-Preferred Drug	34%	N/A	PA QL 9 per 30 days
DROXIDOPA 200 mg Capsule	4Non-Preferred Drug	34%	N/A	PA QL 18 per 30 days
DROXIDOPA 300 mg Capsule	4Non-Preferred Drug	34%	N/A	PA QL 18 per 30 days
DUAVEE .45/20 mg Tablet, Film CoatedConjugated Estrogens/Bazedoxifene	4Non-Preferred Drug	34%	N/A	None
DULERA 100/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate	4Non-Preferred Drug	34%	N/A	QL 13 per 30 days
DULERA 200/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate	4Non-Preferred Drug	34%	N/A	QL 13 per 30 days
DULERA 50/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate	4Non-Preferred Drug	34%	N/A	QL 13 per 30 days
DULOXETINE 20 mg Capsule, Delayed Release	2Generic	$10.00	$0.00	QL 12 per 30 days
DULOXETINE 30 mg Capsule, Delayed Release	2Generic	$10.00	$0.00	QL 9 per 30 days
DULOXETINE 60 mg Capsule, Delayed Release	2Generic	$10.00	$0.00	QL 6 per 30 days
DUPIXENT 200 mg/1.14mL Injection, SolutionDupilumab	5Specialty Tier	31%	N/A	PA QL 4.56 per 28 days
DUPIXENT 200 mg/1.14mL Injection, SolutionDupilumab	5Specialty Tier	31%	N/A	PA QL 4.56 per 28 days
DUPIXENT 300 mg/2mL Injection, SolutionDupilumab	5Specialty Tier	31%	N/A	PA QL 8 per 28 days
DUPIXENT 300 mg/2mL Injection, SolutionDupilumab	5Specialty Tier	31%	N/A	PA QL 8 per 28 days
DUTASTERIDE .5 mg Capsule, Liquid Filled	2Generic	$10.00	$0.00	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.