2009 Medicare Part D Plan Formulary Information |
SilverScript Plus (S5601-049-0)
Benefit Details
|
The SilverScript Plus (S5601-049-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 24 which includes: KS
|
Drugs Starting with Letter D
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
D.H.E.45 1MG/ML AMPUL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
D5-1/2NS/KCL 30MEQ/L IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
D5LR-KCL 40MEQ/L IV SOLUTION |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
D5W/KCL 20MEQ/L IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
D5W/KCL 30MEQ/L IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
DACARBAZINE 100MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DACARBAZINE 200MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DACOGEN INJ 50MG |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DANAZOL 100MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DANAZOL 50MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANAZOL CAPSULES USP 200MG (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DANTRIUM 100MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DANTRIUM 25MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DANTRIUM 50MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DAPSONE 100MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DAPSONE 25MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DARAPRIM 25MG TABLET |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DARVOCET A500 100-500MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DARVOCET-N 100 100-650MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DARVOCET-N 50 50MG-325MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DARVON CAPSULES 65MG (100 CT) |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DARVON-N 100MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DAUNORUBICIN 5MG/ML VIAL |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DAUNORUBICIN HCL POWDER FOR INJECTION USP 20MG 1 VIALSD |
2 |
Generic |
$9.00 | $23.00 | None |
DAUNOXOME 2MG/ML VIAL |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DAYPRO 600MG CAPLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DAYTRANA 10MG/9 HR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DAYTRANA 30MG/9 HOUR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAYTRANA ER PATCH 41.3MG 10 CRTN |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DAYTRANA ER PATCH 55MG 30 CRTN |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DDAVP 0.01% NASAL SPRAY |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DDAVP 0.1MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DDAVP 0.2MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DDAVP 4MCG/ML AMPUL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DECAVAC VACCINE 2;5 UNT/0.5 ML |
4 |
Preferred Brand |
$35.00 | $82.00 | P |
DECLOMYCIN 150MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DECLOMYCIN 300MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEL-BETA 0.05% LOTION |
2 |
Generic |
$9.00 | $23.00 | None |
DELESTROGEN 40MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DELESTROGEN INJECTION 20MG/5ML VIALMD |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMADEX 100MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMADEX 10MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMADEX 10MG/ML AMPUL |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DEMADEX 20MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMADEX 5MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMECLOCYCLINE HCL 150MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DEMECLOCYCLINE HCL 300MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DEMEROL 100MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMEROL 100MG/ML SYRINGE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEMEROL 25MG/ML SYRINGE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMEROL 50MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMEROL 50MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMEROL 75MG/1.5ML AMPUL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMEROL 75MG/ML SYRINGE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DENAVIR 1% CREAM |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DEPACON INJ 100MG/ML |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPADE 50MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DEPAKENE 250MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPAKENE 250MG/5ML SYRUP |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPAKOTE 125MG SPRINKLE CAP |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPAKOTE 125MG TABLET EC |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPAKOTE 250MG TABLET EC |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPAKOTE 500MG TABLET EC |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPAKOTE ER 250MG TABLET SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPAKOTE ER 500MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPEN 250MG TITRATAB |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-MEDROL 20MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-MEDROL 40MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-MEDROL 80MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-PROVERA 150MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DEPO-SQ PROV INJ 104 |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-TESTOSTERONE 100MG/ML |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DEPO-TESTOSTERONE 200MG/ML |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DERMA-SMOOTHE/FS 0.01% BODY OIL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DERMA-SMOOTHE/FS SCALP OIL 0.01% |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DERMATOP 0.1% CREAM |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DERMATOP 0.1% OINTMENT |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DERMOTIC 0.01% DROPS |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DESIPRAMINE 10MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 150MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DESIPRAMINE 25MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DESIPRAMINE 50MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DESIPRAMINE HCL TABLET 100MG (500 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DESMOPRESSIN 0.1MG/ML SOL |
2 |
Generic |
$9.00 | $23.00 | None |
DESMOPRESSIN AC 4MCG/ML VL |
2 |
Generic |
$9.00 | $23.00 | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DESOGEN 28 DAY TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DESONATE (DESONIDE) 0.05% GEL (GM) TOPICAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONIDE 0.05% CREAM |
2 |
Generic |
$9.00 | $23.00 | None |
DESONIDE 0.05% LOTION |
2 |
Generic |
$9.00 | $23.00 | None |
DESONIDE 0.05% OINTMENT 60GM TUBE |
2 |
Generic |
$9.00 | $23.00 | None |
DESOWEN 0.05% CREAM |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DESOWEN 0.05% LOTION |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DESOWEN 0.05% OINTMENT |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DESOXIMETASONE 0.05% CREAM |
2 |
Generic |
$9.00 | $23.00 | None |
DESOXIMETASONE 0.05% GEL |
2 |
Generic |
$9.00 | $23.00 | None |
DESOXIMETASONE 0.25% CREAM |
2 |
Generic |
$9.00 | $23.00 | None |
DESOXIMETASONE 0.25% OINT |
2 |
Generic |
$9.00 | $23.00 | None |
DESOXYN 5MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DETROL 1MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DETROL 2MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DETROL LA 2MG CAPSULE SA |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DETROL LA 4MG CAPSULE SA |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
2 |
Generic |
$9.00 | $23.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 0.5MG/5ML LIQ |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 1MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 2MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
2 |
Generic |
$9.00 | $23.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
2 |
Generic |
$9.00 | $23.00 | None |
DEXASPORIN EYE DROPS |
1 |
Value Generic |
$4.00 | $10.00 | None |
DEXCHLORPHEN 2MG/5ML SYRUP |
2 |
Generic |
$9.00 | $23.00 | None |
DEXEDRINE D-AMPHETAMINE SULFATE 10MG CAPSULE SA ORAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DEXEDRINE D-AMPHETAMINE SULFATE 15MG CAPSULE SA ORAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DEXEDRINE SPANSULE 5MG |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
2 |
Generic |
$9.00 | $23.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
2 |
Generic |
$9.00 | $23.00 | P |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
2 |
Generic |
$9.00 | $23.00 | P |
DEXPAK 1.5MG TABLET |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DEXRAZOXANE 250MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DEXRAZOXANE 500MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROAMPHETAMINE 10MG TABLET |
2 |
Generic |
$9.00 | $23.00 | P |
DEXTROAMPHETAMINE 5MG TABLET |
2 |
Generic |
$9.00 | $23.00 | P |
DEXTROAMPHETAMINE SACCHARATE AMPHETAMINE ASPARATE |
2 |
Generic |
$9.00 | $23.00 | P |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Generic |
$9.00 | $23.00 | P |
DEXTROAMPHETAMINE SULFATE 10MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | P |
DEXTROAMPHETAMINE SULFATE 15MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMPHETAMINE SULFATE 5MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | P |
DEXTROSE 10%-1/4NS IV TUBEX |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5% AND 0.45% NACL INJECTION 5-450 24 X 500ML BAG |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5%-1/3NS IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5%-ELECTROLYTE 75 |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5%-LR IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE 5%-NS IV SOLUTION |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DEXTROSE IN LACTATED RINGERS SOLUTION FOR INJECTION 1000ML PLASTIC BAG X 12 CASE |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
2 |
Generic |
$9.00 | $23.00 | None |
DEXTROSTAT 10MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P |
DEXTROSTAT 5MG TABLET |
2 |
Generic |
$9.00 | $23.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIABETA 1.25MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIABETA 2.5MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIABETA 5MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIABETIC SUPPLIES, MISC 0 N/A INJC |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DIABINESE 100MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIABINESE 250MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIAMOX SEQUELS 500MG CAPSULE SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIBENZYLINE 10MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DICLOFENAC 25MG TABLET EC |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOFENAC SOD 100MG TABLET SA |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SOD 100MG TABLET SA |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOFENAC SODIUM 0.1% DROPS |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOXACILLIN 250MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
2 |
Generic |
$9.00 | $23.00 | None |
DICYCLOMINE 10MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DICYCLOMINE 10MG/ML VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
2 |
Generic |
$9.00 | $23.00 | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIDANOSINE 200MG CAPSULE DELAYED RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DIDANOSINE 250MG CAPSULE DELAYED RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
2 |
Generic |
$9.00 | $23.00 | None |
DIDRONEL 200MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIDRONEL 400MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFFERIN 0.1% CREAM |
4 |
Preferred Brand |
$35.00 | $82.00 | P |
DIFFERIN 0.1% GEL |
4 |
Preferred Brand |
$35.00 | $82.00 | P |
DIFFERIN 0.3% GEL |
4 |
Preferred Brand |
$35.00 | $82.00 | P |
DIFLORASONE 0.05% CREAM |
2 |
Generic |
$9.00 | $23.00 | None |
DIFLORASONE 0.05% OINTMENT |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLUCAN 100MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN 150MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN 200MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN 200MG/5ML SUSPEN |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN 50MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN 50MG/5ML SUSPEN |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN INJECTION 200MG 100ML BOT |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN INJECTION 400MG 6 X 200ML BAG |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN/DEXTRSE 0.4G/200ML |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUCAN/DEXTRSE 200MG/100ML |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIFLUNISAL 500MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGITEK 125MCG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DIGITEK 250MCG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DIGOXIN 125MCG TABLET |
1 |
Value Generic |
$4.00 | $10.00 | None |
DIGOXIN 250MCG TABLET (1000 CT) |
1 |
Value Generic |
$4.00 | $10.00 | None |
DIGOXIN 50MCG/ML SOLUTION ORAL |
1 |
Value Generic |
$4.00 | $10.00 | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
2 |
Generic |
$9.00 | $23.00 | None |
DIHYDROERGOTAMINE 1MG/ML AM |
2 |
Generic |
$9.00 | $23.00 | None |
DILACOR XR 120MG CAPSULE SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILACOR XR 180MG CAPSULE SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILACOR XR 240MG CAPSULE SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILANTIN 30MG KAPSEAL |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILANTIN 50MG INFATAB |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DILANTIN-125 SUS 125/5ML |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DILATRATE-SR 40MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILAUDID 2MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILAUDID 4MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILAUDID 8MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILAUDID-5 1MG/ML LIQUID |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DILAUDID-HP 10MG/ML VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILAUDID-HP 250MG VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILT-CD 120MG CAPSULE SR 24 HR |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILT-CD 180MG CAPSULE SR 24 HR |
2 |
Generic |
$9.00 | $23.00 | None |
DILT-CD 240MG CAPSULE SR 24 HR |
2 |
Generic |
$9.00 | $23.00 | None |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
2 |
Generic |
$9.00 | $23.00 | None |
DILT-XR 120MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM 30MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM 90MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 120MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM ER 180MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 180MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 300MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 360MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM ER 420MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 100MG VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE (90 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 120MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 180MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 240MG ER CAPSULE (90 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 300MG ER CAPSULE (90 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 360MG ER CAPSULE (30 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 60MG ER CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 60MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL 90MG ER CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DILTIAZEM HCL INJECTION 5MG 10 5ML VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DIOVAN 160MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN 320MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN 40MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN 80MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN HCT 160/12.5MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN HCT 160/25MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN HCT 320/12.5MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN HCT 320/25MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIOVAN HCT 80/12.5MG TABLET |
3 |
Value Brand |
$30.00 | $71.00 | None |
DIPENTUM 250MG CAPSULE |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DIPHENHYDRAMINE 25MG CAPSULE |
1 |
Value Generic |
$4.00 | $10.00 | None |
DIPHENHYDRAMINE 50MG CAPS |
1 |
Value Generic |
$4.00 | $10.00 | None |
DIPHENHYDRAMINE ELIXIR BOTTLE |
2 |
Generic |
$9.00 | $23.00 | None |
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
2 |
Generic |
$9.00 | $23.00 | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
2 |
Generic |
$9.00 | $23.00 | P |
DIPIVEFRIN 0.1% EYE DROPS |
2 |
Generic |
$9.00 | $23.00 | None |
DIPROLENE 0.05% LOTION |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIPROLENE 0.05% OINTMENT |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIPROLENE AF 0.05% CREAM |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIPYRIDAMOLE 25MG TABLET (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DIPYRIDAMOLE 50MG TABLET (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DIPYRIDAMOLE 75MG TABLET (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DISOPYRAMIDE 150MG CAPSULE SA |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DITROPAN 5MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DITROPAN 5MG/5ML SYRUP |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DITROPAN XL 10MG TABLET SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DITROPAN XL 15MG TABLET SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DITROPAN XL 5MG TABLET SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIURIL SODIUM 500MG VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIVALPROEX SODIUM 125MG TBEC |
2 |
Generic |
$9.00 | $23.00 | None |
DIVALPROEX SODIUM 250MG TBEC |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM 500MG TBEC |
2 |
Generic |
$9.00 | $23.00 | None |
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT |
2 |
Generic |
$9.00 | $23.00 | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
2 |
Generic |
$9.00 | $23.00 | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
2 |
Generic |
$9.00 | $23.00 | None |
DIVIGEL 0.25(0.1%) GEL IN PACKET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIVIGEL 0.5MG(0.1) GEL IN PACKET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DIVIGEL 1MG(0.1%) GEL IN PACKET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DOLOPHINE HCL 10MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:240 /25Days |
DOLOPHINE HCL 5MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:240 /25Days |
DOLOREX FORTE 5MG-500MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DORIBAX INJECTION |
6 |
Specialty |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORYX 100MG TABLET DR |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DORYX 75MG TABLET DR |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DORYX DELAYED RELEASE TABLETS 150MG |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
2 |
Generic |
$9.00 | $23.00 | None |
DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML; |
2 |
Generic |
$9.00 | $23.00 | None |
DOVONEX 0.005% CREAM |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DOVONEX 0.005% SOLUTION |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DOXAZOSIN MESYLATE TABLET 2MG (500 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DOXAZOSIN MESYLATE TABLET 4MG (500 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DOXAZOSIN MESYLATE TABLET 8MG (500 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DOXAZOSIN TABLET 1MG (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 100MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DOXEPIN 10MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DOXEPIN 10MG/ML ORAL CONC |
2 |
Generic |
$9.00 | $23.00 | None |
DOXEPIN 150MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DOXEPIN 75MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DOXEPIN HCL 50MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DOXIL INJECTION 2MG |
6 |
Specialty |
31% | N/A | None |
DOXORUBICIN 10MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DOXORUBICIN 50MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE 100MG CAPSULE |
1 |
Value Generic |
$4.00 | $10.00 | None |
DOXYCYCLINE 100MG VIAL |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Value Generic |
$4.00 | $10.00 | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT) |
1 |
Value Generic |
$4.00 | $10.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Value Generic |
$4.00 | $10.00 | None |
DOXYCYCLINE HYCLATE 75MG CAPSULE DELAYED RELEASE (60 CT) |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DOXYCYCLINE MONO 100MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE MONO 50MG CAPSULE |
2 |
Generic |
$9.00 | $23.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE MONOHYDRATE 25MG/5ML SUSR |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE TABLET 100MG (250 CT) |
2 |
Generic |
$9.00 | $23.00 | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
2 |
Generic |
$9.00 | $23.00 | None |
DRONABINOL CAPS 10MG |
2 |
Generic |
$9.00 | $23.00 | Q:60 /25Days |
DRONABINOL CAPS 2.5MG |
2 |
Generic |
$9.00 | $23.00 | Q:60 /25Days |
DRONABINOL CAPS 5MG |
2 |
Generic |
$9.00 | $23.00 | Q:60 /25Days |
DROXIA 200MG CAPSULE |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DROXIA 300MG CAPSULE |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DROXIA 400MG CAPSULE |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DTIC-DOME IV 200MG VIAL |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DUETACT 30MG-2MG TABLET |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DUETACT 30MG-4MG TABLET |
4 |
Preferred Brand |
$35.00 | $82.00 | None |
DUONEB INHALATION SOLUTION 3-.5MG 60 X 3ML CRTN |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | P Q:540 /25Days |
DURAGESIC 100MCG/HR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:10 /25Days |
DURAGESIC 12 MCG/HR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:10 /25Days |
DURAGESIC 25MCG/HR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:10 /25Days |
DURAGESIC 50MCG/HR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:10 /25Days |
DURAGESIC 75MCG/HR PATCH |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | Q:10 /25Days |
DURAMORPH 0.5MG/ML AMPUL |
2 |
Generic |
$9.00 | $23.00 | None |
DURAMORPH 1MG/ML AMPUL |
2 |
Generic |
$9.00 | $23.00 | None |
DYAZIDE 37.5/25 CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYGASE 30-2.4-30 CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYNACIN 100MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYNACIN 50MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYNACIN 75MG TABLET |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYNACIRC CR 10MG TABLET SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYNACIRC CR 5MG TABLET SA |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYRENIUM 100MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |
DYRENIUM 50MG CAPSULE |
5 |
Non-Preferred Brand |
$95.00 | $261.00 | None |