MedicarePartD.guide

A non-government resource built from CMS public data

2026 Blue Rx PDP Plus (PDP) formulary (drug list)

Contract S5593, plan 002 · West Virginia · 3,788 drugs on file · formulary ID 00026017. Each drug links to its cost in every CMS PDP Region 06 plan.

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254 drugs starting with D.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
DABIGATRAN ETEXILATE 110 mg Capsule4Non-Preferred Drug25%25%
  • QL 124 per 31 days
DABIGATRAN ETEXILATE 150 mg Capsule4Non-Preferred Drug25%25%
  • QL 62 per 31 days
DABIGATRAN ETEXILATE 75 mg Capsule4Non-Preferred Drug25%25%
  • QL 62 per 31 days
DALBAVANCIN 500 mg/25mL Injection, Powder, Lyophilized, For Solution5Specialty Tier25%25%None
DALFAMPRIDINE 10 mg Tablet, Film Coated, Extended Release5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
DANAZOL 100 mg Capsule2Generic25%25%None
DANAZOL 200 mg Capsule2Generic25%25%None
DANAZOL 50 mg Capsule2Generic25%25%None
DANTROLENE SODIUM 100 mg Capsule4Non-Preferred Drug25%25%None
DANTROLENE SODIUM 25 mg Capsule4Non-Preferred Drug25%25%None
DANTROLENE SODIUM 50 mg Capsule4Non-Preferred Drug25%25%None
DANZITEN 71 mg TabletNilotinib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
DANZITEN 95 mg TabletNilotinib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
DAPAGLIFLOZIN 10 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 31 per 31 days
DAPAGLIFLOZIN 5 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 31 per 31 days
DAPSONE 100 mg Tablet3Preferred Brand25%25%None
DAPSONE 25 mg Tablet3Preferred Brand25%25%None
DAPSONE 50 mg/g Gel4Non-Preferred Drug25%25%
  • QL 9 per 28 days
DAPSONE 75 mg/g GelDaspone4Non-Preferred Drug25%25%
  • QL 9 per 28 days
DAPTOMYCIN 350 mg/7mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug25%25%None
DAPTOMYCIN 500 mg/10mL Injection, Powder, Lyophilized, For Solution5Specialty Tier25%25%None
DARIFENACIN 15 mg Tablet, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DARIFENACIN 7.5 mg Tablet, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DARUNAVIR 600 mg Tablet, Film Coated4Non-Preferred Drug25%25%None
DARUNAVIR 800 mg Tablet, Film Coated5Specialty Tier25%25%None
DASATINIB 100 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
DASATINIB 140 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
DASATINIB 20 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 93 per 31 days
DASATINIB 50 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
DASATINIB 70 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
DASATINIB 80 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
DAURISMO 100 mg Tablet, Film CoatedGlasdegib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
DAURISMO 25 mg Tablet, Film CoatedGlasdegib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
DEFERASIROX 125 mg Tablet, For Suspension4Non-Preferred Drug25%25%
  • PA
DEFERASIROX 250 mg Tablet, For Suspension5Specialty Tier25%25%
  • PA
DEFERASIROX 500 mg Tablet, For Suspension5Specialty Tier25%25%
  • PA
DELSTRIGO 100/300/300 mg Tablet, Film CoatedDoravirine, Lamivudine, And Tenofovir Disoproxil Fumarate5Specialty Tier25%25%
  • QL 31 per 31 days
DEMECLOCYCLINE HYDROCHLORIDE 150 mg TabletDemeclocycline2Generic25%25%None
DEMECLOCYCLINE HYDROCHLORIDE 300 mg TabletDemeclocycline4Non-Preferred Drug25%25%None
DEPO-ESTRADIOL 5 mg/mL InjectionEstradiol Cypionate4Non-Preferred Drug25%25%None
DEPO-SUBQ PROVERA 104 mg/.65mL Injection, SuspensionMedroxyprogesterone Acetate3Preferred Brand25%25%None
DEPO-TESTOSTERONE 100 mg/mL Injection, SolutionTestosterone Cypionate4Non-Preferred Drug25%25%
  • PA
DESCOVY 120/15 mg TabletEmtricitabine And Tenofovir Alafenamide5Specialty Tier25%25%
  • QL 31 per 31 days
DESCOVY 200/25 mg TabletEmtricitabine And Tenofovir Alafenamide5Specialty Tier25%25%
  • QL 31 per 31 days
DESIPRAMINE HYDROCHLORIDE 10 mg Tablet3Preferred Brand25%25%None
DESIPRAMINE HYDROCHLORIDE 100 mg Tablet4Non-Preferred Drug25%25%None
DESIPRAMINE HYDROCHLORIDE 150 mg Tablet4Non-Preferred Drug25%25%None
DESIPRAMINE HYDROCHLORIDE 25 mg Tablet3Preferred Brand25%25%None
DESIPRAMINE HYDROCHLORIDE 50 mg Tablet3Preferred Brand25%25%None
DESIPRAMINE HYDROCHLORIDE 75 mg Tablet4Non-Preferred Drug25%25%None
DESLORATADINE 5 mg Tablet, Film Coated2Generic25%25%
  • QL 31 per 31 days
DESMOPRESSIN ACETATE .1 mg Tablet2Generic25%25%None
DESMOPRESSIN ACETATE .1 mg/mL Solution4Non-Preferred Drug25%25%None
DESMOPRESSIN ACETATE .2 mg Tablet2Generic25%25%None
DESONIDE .5 mg/g Cream3Preferred Brand25%25%
  • QL 6 per 28 days
DESONIDE .5 mg/g Gel3Preferred Brand25%25%
  • QL 6 per 28 days
DESONIDE .5 mg/g Ointment3Preferred Brand25%25%
  • QL 6 per 28 days
DESONIDE .5 mg/mL Lotion3Preferred Brand25%25%
  • QL 118 per 28 days
DESOXIMETASONE .5 mg/g Cream2Generic25%25%
  • QL 1 per 28 days
DESOXIMETASONE .5 mg/g Gel2Generic25%25%
  • QL 6 per 28 days
DESOXIMETASONE 2.5 mg/g Cream2Generic25%25%
  • QL 1 per 28 days
DESOXIMETASONE 2.5 mg/g Ointment2Generic25%25%
  • QL 1 per 28 days
DESOXIMETASONE 2.5 mg/mL Spray2Generic25%25%
  • QL 1 per 28 days
DESVENLAFAXINE 100 mg Tablet, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DESVENLAFAXINE 100 mg Tablet, Extended Release4Non-Preferred Drug25%25%
  • QL 124 per 31 days
DESVENLAFAXINE 25 mg Tablet, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DESVENLAFAXINE 50 mg Tablet, Extended Release4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DESVENLAFAXINE 50 mg Tablet, Film Coated, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DEXAMETHASONE .5 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE .5 mg/5mL Solution1Preferred Generic25%25%None
DEXAMETHASONE .75 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE 1 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE 1.5 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE 2 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE 4 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE 6 mg Tablet1Preferred Generic25%25%None
DEXAMETHASONE SODIUM PHOSPHATE 1 mg/mL Solution/ Drops2Generic25%25%None
DEXMETHYLPHENIDATE HYDROCHLORIDE 10 mg Capsule, Extended Release4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet2Generic25%25%
  • QL 62 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 2.5 mg Tablet2Generic25%25%
  • QL 93 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 20 mg Capsule, Extended Release4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 35 mg Capsule, Extended Release4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE 5 mg Tablet2Generic25%25%
  • QL 93 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 15 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 25 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 30 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 40 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXMETHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 5 mg Capsule, Extended ReleaseDexmethylphenidate Hydrochloride4Non-Preferred Drug25%25%
  • QL 31 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 7.5/7.5/7.5/7.5 mg Capsule, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Capsule, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Capsule, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 6.25/6.25/6.25/6.25 mg Capsule, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Tablet1Preferred Generic25%25%
  • QL 62 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.875/1.875/1.875/1.875 mg Tablet1Preferred Generic25%25%
  • QL 62 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 2.5/2.5/2.5/2.5 mg Tablet1Preferred Generic25%25%
  • QL 62 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 3.125/3.125/3.125/3.125 mg Tablet2Generic25%25%
  • QL 62 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Tablet1Preferred Generic25%25%
  • QL 62 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 5/5/5/5 mg Tablet1Preferred Generic25%25%
  • QL 93 per 31 days
DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 7.5/7.5/7.5/7.5 mg Tablet1Preferred Generic25%25%
  • QL 62 per 31 days
DEXTROAMPHETAMINE SULFATE 10 mg Tablet4Non-Preferred Drug25%25%
  • QL 186 per 31 days
DEXTROAMPHETAMINE SULFATE 5 mg Tablet4Non-Preferred Drug25%25%
  • QL 341 per 31 days
DEXTROSE 100 g/1000mL Injection, SolutionDextrose Monohydrate2Generic25%25%None
DEXTROSE 50 mg/mL Injection, SolutionDextrose Monohydrate2Generic25%25%None
DEXTROSE AND SODIUM CHLORIDE 10/.45 g/100mL Injection, Solution2Generic25%25%None
DEXTROSE AND SODIUM CHLORIDE 2.5/450 g/100mL/mg/100mL Injection, Solution2Generic25%25%None
DEXTROSE AND SODIUM CHLORIDE 5/.2 g/100mL Injection, Solution2Generic25%25%None
DEXTROSE AND SODIUM CHLORIDE 5/.9 g/100mL Injection, SolutionDextrose Monohydrate And Sodium Chloride2Generic25%25%None
DIACOMIT 250 mg CapsuleStiripentol5Specialty Tier25%25%
  • PA
  • QL 341 per 31 days
DIACOMIT 250 mg Powder, For SuspensionStiripentol5Specialty Tier25%25%
  • PA
  • QL 341 per 31 days
DIACOMIT 500 mg CapsuleStiripentol5Specialty Tier25%25%
  • PA
  • QL 186 per 31 days
DIACOMIT 500 mg Powder, For SuspensionStiripentol5Specialty Tier25%25%
  • PA
  • QL 186 per 31 days
DIAZEPAM 10 mg Tablet2Generic25%25%
  • PA
  • QL 124 per 31 days
DIAZEPAM 2 mg Tablet2Generic25%25%
  • PA
  • QL 124 per 31 days
DIAZEPAM 2.5 mg/.5mL Gel4Non-Preferred Drug25%25%None
DIAZEPAM 5 mg Tablet2Generic25%25%
  • PA
  • QL 124 per 31 days
DIAZEPAM 5 mg/5mL Solution2Generic25%25%
  • PA
  • QL 15 per 31 days
DIAZEPAM INTENSOL 5 mg/mL Solution, Concentrate2Generic25%25%
  • PA
  • QL 248 per 31 days
DIAZOXIDE 50 mg/mL Suspension4Non-Preferred Drug25%25%None
DICLOFENAC EPOLAMINE .013 g System4Non-Preferred Drug25%25%
  • PA
  • QL 62 per 31 days
DICLOFENAC POTASSIUM 50 mg Tablet, Film Coated1Preferred Generic25%25%None
DICLOFENAC SODIUM 1 mg/mL Solution/ Drops1Preferred Generic25%25%None
DICLOFENAC SODIUM 100 mg Tablet, Film Coated, Extended Release1Preferred Generic25%25%None
DICLOFENAC SODIUM 16.05 mg/mL Solution2Generic25%25%
  • QL 45 per 28 days
DICLOFENAC SODIUM 25 mg Tablet, Delayed Release1Preferred Generic25%25%None
DICLOFENAC SODIUM 30 mg/g Gel4Non-Preferred Drug25%25%
  • PA
  • QL 1 per 28 days
DICLOFENAC SODIUM 50 mg Tablet, Delayed Release1Preferred Generic25%25%None
DICLOFENAC SODIUM 75 mg Tablet, Delayed Release1Preferred Generic25%25%None
DICLOFENAC SODIUM AND MISOPROSTOL 50/200 mg/ug Tablet, Film Coated3Preferred Brand25%25%None
DICLOFENAC SODIUM AND MISOPROSTOL 75/200 mg/ug Tablet, Film Coated3Preferred Brand25%25%None
DICLOXACILLIN SODIUM 250 mg Capsule2Generic25%25%None
DICLOXACILLIN SODIUM 500 mg Capsule2Generic25%25%None
DICYCLOMINE 20 mg TabletDicyclomine Hydrochloride2Generic25%25%None
DICYCLOMINE HYDROCHLORIDE 10 mg Capsule2Generic25%25%None
DICYCLOMINE HYDROCHLORIDE 10 mg/5mL Solution2Generic25%25%None
DIFICID 200 mg/5mL Granule, For SuspensionFidaxomicin5Specialty Tier25%25%
  • QL 136 per 12 days
DIFLUNISAL 500 mg Tablet, Film Coated2Generic25%25%None
DIFLUPREDNATE OPHTHALMIC EMULSION .5 mg/mL EmulsionDifluprednate Ophthalmic4Non-Preferred Drug25%25%None
DIGOXIN .05 mg/mL Solution3Preferred Brand25%25%
  • QL 155 per 31 days
DIGOXIN .0625 mg Tablet4Non-Preferred Drug25%25%
  • QL 124 per 31 days
DIGOXIN 125 ug Tablet1Preferred Generic25%25%
  • QL 62 per 31 days
DIGOXIN 250 ug Tablet2Generic25%25%
  • QL 31 per 31 days
DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered5Specialty Tier25%25%
  • PA
  • QL 8 per 28 days
DILANTIN 100 mg Capsule, Extended ReleaseExtended Phenytoin Sodium4Non-Preferred Drug25%25%None
DILANTIN 30 mg Capsule, Extended ReleaseExtended Phenytoin Sodium3Preferred Brand25%25%None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 120 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 120 mg Tablet, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 120 mg Tablet, Film Coated1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 180 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 180 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 180 mg Tablet, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 240 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 240 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 240 mg Tablet, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 30 mg Tablet, Film Coated1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 300 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 300 mg Tablet, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 360 mg Tablet, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 420 mg Tablet, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 60 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 60 mg Tablet, Film Coated1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 90 mg Capsule, Extended Release1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE 90 mg Tablet, Film Coated1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE 360 mg Capsule, Extended ReleaseDiltiazem Hydrochloride1Preferred Generic25%25%None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE 420 mg Capsule, Extended ReleaseDiltiazem Hydrochloride1Preferred Generic25%25%None
DIMETHYL FUMARATE 120 mg Capsule, Delayed Release4Non-Preferred Drug25%25%
  • PA
  • QL 62 per 31 days
DIMETHYL FUMARATE 240 mg Capsule, Delayed Release5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
DIMETHYL FUMARATE Kit5Specialty Tier25%25%
  • PA
  • QL 12 per 365 days
DIPHENOXYLATE HYDROCHLORIDE AND ATROPINE SULFATE 2.5/.025 mg Tablet2Generic25%25%None
DIPHENOXYLATE HYDROCHLORIDE AND ATROPINE SULFATE 2.5/.025 mg/5mL Solution3Preferred Brand25%25%None
DISULFIRAM 250 mg Tablet2Generic25%25%None
DISULFIRAM 500 mg Tablet2Generic25%25%None
DIVALPROEX SODIUM 125 mg Capsule, Coated Pellets2Generic25%25%None
DIVALPROEX SODIUM 125 mg Tablet, Delayed Release2Generic25%25%None
DIVALPROEX SODIUM 250 mg Tablet, Delayed Release2Generic25%25%None
DIVALPROEX SODIUM 250 mg Tablet, Extended Release2Generic25%25%None
DIVALPROEX SODIUM 500 mg Tablet, Delayed Release2Generic25%25%None
DIVALPROEX SODIUM 500 mg Tablet, Extended Release3Preferred Brand25%25%None
DOFETILIDE .125 mg Capsule3Preferred Brand25%25%None
DOFETILIDE .25 mg Capsule3Preferred Brand25%25%None
DOFETILIDE .5 mg Capsule3Preferred Brand25%25%None
DOLISHALE 90/20 ug TabletLevonorgestrel And Ethinyl Estradiol4Non-Preferred Drug25%25%None
DONEPEZIL HYDROCHLORIDE 10 mg Tablet, Film Coated1Preferred Generic25%25%None
DONEPEZIL HYDROCHLORIDE 10 mg Tablet, Orally Disintegrating2Generic25%25%None
DONEPEZIL HYDROCHLORIDE 23 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 31 per 31 days
DONEPEZIL HYDROCHLORIDE 5 mg Tablet, Film Coated1Preferred Generic25%25%None
DONEPEZIL HYDROCHLORIDE 5 mg Tablet, Orally Disintegrating2Generic25%25%None
DORZOLAMIDE HCL 20 mg/mL Solution/ Drops2Generic25%25%None
DORZOLAMIDE HYDROCHLORIDE AND TIMOLOL MALEATE 20/5 mg/mL Solution2Generic25%25%None
DOTTI .025 mg/d Patch, Extended ReleaseEstradiol2Generic25%25%None
DOTTI .0375 mg/d Patch, Extended ReleaseEstradiol2Generic25%25%None
DOTTI .05 mg/d Patch, Extended ReleaseEstradiol2Generic25%25%None
DOTTI .075 mg/d Patch, Extended ReleaseEstradiol2Generic25%25%None
DOTTI .1 mg/d Patch, Extended ReleaseEstradiol2Generic25%25%None
DOVATO 50/300 mg Tablet, Film CoatedDolutegravir Sodium And Lamivudine5Specialty Tier25%25%
  • QL 31 per 31 days
DOXAZOSIN 1 mg Tablet1Preferred Generic25%25%None
DOXAZOSIN 2 mg Tablet1Preferred Generic25%25%None
DOXAZOSIN 4 mg Tablet1Preferred Generic25%25%None
DOXAZOSIN 8 mg Tablet1Preferred Generic25%25%None
DOXEPIN 3 mg Tablet, Film Coated2Generic25%25%
  • PA
DOXEPIN 6 mg Tablet, Film Coated2Generic25%25%
  • PA
DOXEPIN HYDROCHLORIDE 10 mg Capsule2Generic25%25%
  • PA
DOXEPIN HYDROCHLORIDE 10 mg/mL Solution2Generic25%25%
  • PA
DOXEPIN HYDROCHLORIDE 100 mg Capsule2Generic25%25%
  • PA
DOXEPIN HYDROCHLORIDE 25 mg Capsule2Generic25%25%
  • PA
DOXEPIN HYDROCHLORIDE 50 mg Capsule2Generic25%25%
  • PA
DOXEPIN HYDROCHLORIDE 50 mg/g Cream4Non-Preferred Drug25%25%
  • PA
  • QL 45 per 28 days
DOXEPIN HYDROCHLORIDE 75 mg Capsule2Generic25%25%
  • PA
DOXERCALCIFEROL .5 ug Capsule2Generic25%25%
  • PA
DOXERCALCIFEROL 1 ug Capsule4Non-Preferred Drug25%25%
  • PA
DOXERCALCIFEROL 2.5 ug Capsule2Generic25%25%
  • PA
DOXY 100 100 mg/10mL Injection, Powder, Lyophilized, For SolutionDoxycycline3Preferred Brand25%25%None
DOXYCYCLINE 100 mg Capsule2Generic25%25%None
DOXYCYCLINE 100 mg Capsule2Generic25%25%None
DOXYCYCLINE 100 mg Tablet2Generic25%25%None
DOXYCYCLINE 100 mg/10mL Injection, Powder, Lyophilized, For Solution2Generic25%25%None
DOXYCYCLINE 25 mg/5mL For Suspension4Non-Preferred Drug25%25%None
DOXYCYCLINE 50 mg Capsule2Generic25%25%None
DOXYCYCLINE 50 mg Tablet2Generic25%25%None
DOXYCYCLINE 75 mg Tablet2Generic25%25%None
DOXYCYCLINE HYCLATE 20 mg Tablet, Film Coated1Preferred Generic25%25%None
DOXYCYCLINE HYCLATE 200 mg Tablet, Delayed Release3Preferred Brand25%25%None
DOXYCYCLINE HYCLATE 50 mg Capsule2Generic25%25%None
DOXYCYCLINE HYCLATE 50 mg Tablet, Delayed Release3Preferred Brand25%25%None
DOXYCYCLINE HYCLATE 50 mg Tablet, Film Coated4Non-Preferred Drug25%25%None
DOXYCYCLINE HYCLATE DELAYED RELEASE 100 mg Tablet, Delayed ReleaseDoxycycline Hyclate2Generic25%25%None
DOXYCYCLINE HYCLATE DELAYED RELEASE 150 mg Tablet, Delayed ReleaseDoxycycline Hyclate3Preferred Brand25%25%None
DOXYCYCLINE HYCLATE DELAYED RELEASE 75 mg Tablet, Delayed ReleaseDoxycycline Hyclate1Preferred Generic25%25%None
DRIZALMA SPRINKLE 20 mg Capsule, Delayed ReleaseDuloxetine3Preferred Brand25%25%
  • PA
  • QL 93 per 31 days
DRIZALMA SPRINKLE 30 mg Capsule, Delayed ReleaseDuloxetine3Preferred Brand25%25%
  • PA
  • QL 62 per 31 days
DRIZALMA SPRINKLE 40 mg Capsule, Delayed ReleaseDuloxetine3Preferred Brand25%25%
  • PA
  • QL 31 per 31 days
DRIZALMA SPRINKLE 60 mg Capsule, Delayed ReleaseDuloxetine3Preferred Brand25%25%
  • PA
  • QL 62 per 31 days
DRONABINOL 10 mg Capsule4Non-Preferred Drug25%25%
  • PA
DRONABINOL 2.5 mg Capsule4Non-Preferred Drug25%25%
  • PA
DRONABINOL 5 mg Capsule4Non-Preferred Drug25%25%
  • PA
DROSPIRENONE AND ETHINYL ESTRADIOL Kit2Generic25%25%None
DROSPIRENONE AND ETHINYL ESTRADIOL Kit2Generic25%25%None
DROXIDOPA 100 mg Capsule5Specialty Tier25%25%
  • PA
  • QL 465 per 31 days
DROXIDOPA 200 mg Capsule5Specialty Tier25%25%
  • PA
  • QL 186 per 31 days
DROXIDOPA 300 mg Capsule5Specialty Tier25%25%
  • PA
  • QL 186 per 31 days
DULERA 100/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate3Preferred Brand25%25%
  • QL 13 per 30 days
DULERA 200/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate3Preferred Brand25%25%
  • QL 13 per 30 days
DULERA 50/5 ug AerosolMometasone Furoate And Formoterol Fumarate Dihydrate3Preferred Brand25%25%
  • QL 13 per 30 days
DULOXETINE 20 mg Capsule, Delayed Release2Generic25%25%
  • QL 62 per 31 days
DULOXETINE 30 mg Capsule, Delayed Release2Generic25%25%
  • QL 31 per 31 days
DULOXETINE 40 mg Capsule, Delayed Release3Preferred Brand25%25%
  • QL 31 per 31 days
DULOXETINE 60 mg Capsule, Delayed Release2Generic25%25%
  • QL 62 per 31 days
DUOPA 20/4.63 mg/mL SuspensionCarbidopa And Levodopa5Specialty Tier25%25%
  • PA
DUPIXENT 200 mg/1.14mL Injection, SolutionDupilumab5Specialty Tier25%25%
  • PA
  • QL 2.28 per 28 days
DUPIXENT 200 mg/1.14mL Injection, SolutionDupilumab5Specialty Tier25%25%
  • PA
  • QL 2.28 per 28 days
DUPIXENT 300 mg/2mL Injection, SolutionDupilumab5Specialty Tier25%25%
  • PA
  • QL 8 per 28 days
DUPIXENT 300 mg/2mL Injection, SolutionDupilumab5Specialty Tier25%25%
  • PA
  • QL 8 per 28 days
DUTASTERIDE .5 mg Capsule, Liquid Filled2Generic25%25%
  • QL 31 per 31 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.