2009 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan One (S5617-028-0)
Benefit Details
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The CIGNA Medicare Rx Plan One (S5617-028-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 6 which includes: PA WV
|
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 ![Compare how all Medicare Part D PDP plans in PA cover D.H.E.45 1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | Q:10 /1Days |
D5-1/2NS/KCL 30MEQ/L IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover D5-1/2NS/KCL 30MEQ/L IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
D5LR-KCL 40MEQ/L IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover D5LR-KCL 40MEQ/L IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
D5W/KCL 20MEQ/L IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover D5W/KCL 20MEQ/L IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
D5W/KCL 30MEQ/L IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover D5W/KCL 30MEQ/L IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
DACARBAZINE 100MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DACARBAZINE 100MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DACARBAZINE 200MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DACARBAZINE 200MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DACOGEN INJ 50MG ![Compare how all Medicare Part D PDP plans in PA cover DACOGEN INJ 50MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
DANAZOL 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DANAZOL 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DANAZOL 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DANAZOL 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANAZOL CAPSULES USP 200MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DANAZOL CAPSULES USP 200MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DANTROLENE SODIUM 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DANTROLENE SODIUM 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DANTROLENE SODIUM 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DANTROLENE SODIUM 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DANTROLENE SODIUM 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DANTROLENE SODIUM 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DAPSONE 100MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DAPSONE 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DAPSONE 25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DAPSONE 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML ![Compare how all Medicare Part D PDP plans in PA cover DAPTACEL VACCINE 15;5;5;3; LF/.5ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DARAPRIM 25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DARAPRIM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DAUNORUBICIN 5MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DAUNORUBICIN 5MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
DAUNORUBICIN HCL POWDER FOR INJECTION USP 20MG 1 VIALSD ![Compare how all Medicare Part D PDP plans in PA cover DAUNORUBICIN HCL POWDER FOR INJECTION USP 20MG 1 VIALSD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
DAUNOXOME 2MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DAUNOXOME 2MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAYTRANA 10MG/9 HR PATCH ![Compare how all Medicare Part D PDP plans in PA cover DAYTRANA 10MG/9 HR PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DAYTRANA 30MG/9 HOUR PATCH ![Compare how all Medicare Part D PDP plans in PA cover DAYTRANA 30MG/9 HOUR PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DAYTRANA ER PATCH 41.3MG 10 CRTN ![Compare how all Medicare Part D PDP plans in PA cover DAYTRANA ER PATCH 41.3MG 10 CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DAYTRANA ER PATCH 55MG 30 CRTN ![Compare how all Medicare Part D PDP plans in PA cover DAYTRANA ER PATCH 55MG 30 CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DECLOMYCIN 150MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DECLOMYCIN 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DECLOMYCIN 300MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DECLOMYCIN 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DEGARELIX INJ ![Compare how all Medicare Part D PDP plans in PA cover DEGARELIX INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEGARELIX SOLR ![Compare how all Medicare Part D PDP plans in PA cover DEGARELIX SOLR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEL-BETA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in PA cover DEL-BETA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DELESTROGEN 40MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DELESTROGEN 40MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DELESTROGEN INJECTION 10MG/5ML VIALMD ![Compare how all Medicare Part D PDP plans in PA cover DELESTROGEN INJECTION 10MG/5ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DELESTROGEN INJECTION 20MG/5ML VIALMD ![Compare how all Medicare Part D PDP plans in PA cover DELESTROGEN INJECTION 20MG/5ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DEMECLOCYCLINE HCL 150MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEMECLOCYCLINE HCL 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DEMECLOCYCLINE HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEMECLOCYCLINE HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DEMEROL 100MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DEMEROL 100MG/ML SYRINGE ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 100MG/ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEMEROL 25MG/ML SYRINGE ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 25MG/ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEMEROL 50MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DEMEROL 50MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 50MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEMEROL 75MG/1.5ML AMPUL ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 75MG/1.5ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEMEROL 75MG/ML SYRINGE ![Compare how all Medicare Part D PDP plans in PA cover DEMEROL 75MG/ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DENAVIR 1% CREAM ![Compare how all Medicare Part D PDP plans in PA cover DENAVIR 1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPACON INJ 100MG/ML ![Compare how all Medicare Part D PDP plans in PA cover DEPACON INJ 100MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEPADE 50MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEPADE 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEPAKOTE 125MG SPRINKLE CAP ![Compare how all Medicare Part D PDP plans in PA cover DEPAKOTE 125MG SPRINKLE CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEPAKOTE 125MG TABLET EC ![Compare how all Medicare Part D PDP plans in PA cover DEPAKOTE 125MG TABLET EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEPAKOTE 250MG TABLET EC ![Compare how all Medicare Part D PDP plans in PA cover DEPAKOTE 250MG TABLET EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEPAKOTE 500MG TABLET EC ![Compare how all Medicare Part D PDP plans in PA cover DEPAKOTE 500MG TABLET EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEPAKOTE ER 250MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover DEPAKOTE ER 250MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DEPAKOTE ER 500MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEPAKOTE ER 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DEPEN 250MG TITRATAB ![Compare how all Medicare Part D PDP plans in PA cover DEPEN 250MG TITRATAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEPO-MEDROL 20MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DEPO-MEDROL 20MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DEPO-MEDROL 40MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DEPO-MEDROL 40MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-MEDROL 80MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DEPO-MEDROL 80MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DERMOTIC 0.01% DROPS ![Compare how all Medicare Part D PDP plans in PA cover DERMOTIC 0.01% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DESIPRAMINE 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESIPRAMINE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESIPRAMINE 150MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESIPRAMINE 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESIPRAMINE 25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESIPRAMINE 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESIPRAMINE 50MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESIPRAMINE 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DESIPRAMINE HCL 75MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESIPRAMINE HCL TABLET 100MG (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DESIPRAMINE HCL TABLET 100MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESMOPRESSIN 0.1MG/ML SOL ![Compare how all Medicare Part D PDP plans in PA cover DESMOPRESSIN 0.1MG/ML SOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DESMOPRESSIN AC 4MCG/ML VL ![Compare how all Medicare Part D PDP plans in PA cover DESMOPRESSIN AC 4MCG/ML VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
DESMOPRESSIN ACETATE 0.1MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESMOPRESSIN ACETATE 0.1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DESOGEN 28 DAY TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESOGEN 28 DAY TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DESONIDE 0.05% CREAM ![Compare how all Medicare Part D PDP plans in PA cover DESONIDE 0.05% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESONIDE 0.05% LOTION ![Compare how all Medicare Part D PDP plans in PA cover DESONIDE 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESONIDE 0.05% OINTMENT 60GM TUBE ![Compare how all Medicare Part D PDP plans in PA cover DESONIDE 0.05% OINTMENT 60GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESOXIMETASONE 0.05% CREAM ![Compare how all Medicare Part D PDP plans in PA cover DESOXIMETASONE 0.05% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESOXIMETASONE 0.05% GEL ![Compare how all Medicare Part D PDP plans in PA cover DESOXIMETASONE 0.05% GEL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESOXIMETASONE 0.25% CREAM ![Compare how all Medicare Part D PDP plans in PA cover DESOXIMETASONE 0.25% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESOXIMETASONE 0.25% OINT ![Compare how all Medicare Part D PDP plans in PA cover DESOXIMETASONE 0.25% OINT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DESOXYN 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DESOXYN 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DETROL 1MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DETROL 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DETROL 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DETROL 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:60 /30Days |
DETROL LA 2MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DETROL LA 2MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DETROL LA 4MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DETROL LA 4MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DEXAMETHASONE 0.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 0.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 0.5MG/0.5ML DROP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 0.5MG/5ML ELX ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 0.5MG/5ML ELX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 0.5MG/5ML LIQ ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 0.5MG/5ML LIQ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 0.75MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 0.75MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 1.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 1.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 1MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 4MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 4MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE 6MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE 6MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD ![Compare how all Medicare Part D PDP plans in PA cover DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXASPORIN EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover DEXASPORIN EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXCHLORPHEN 2MG/5ML SYRUP ![Compare how all Medicare Part D PDP plans in PA cover DEXCHLORPHEN 2MG/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXMETHYLPHENIDATE HCL 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXMETHYLPHENIDATE HCL 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXMETHYLPHENIDATE HCL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXMETHYLPHENIDATE HCL 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXMETHYLPHENIDATE HCL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXPAK 1.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXPAK 1.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXRAZOXANE 250MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DEXRAZOXANE 250MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXRAZOXANE 500MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DEXRAZOXANE 500MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
DEXTROAMPHETAMINE 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROAMPHETAMINE 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROAMPHETAMINE SACCHARATE AMPHETAMINE ASPARATE ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE SACCHARATE AMPHETAMINE ASPARATE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROAMPHETAMINE SULFATE 10MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE SULFATE 10MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROAMPHETAMINE SULFATE 15MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE SULFATE 15MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROAMPHETAMINE SULFATE 5MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DEXTROAMPHETAMINE SULFATE 5MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROSE 10%-1/4NS IV TUBEX ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 10%-1/4NS IV TUBEX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 2.5%-1/2NS IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 2.5%-1/2NS IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 5% AND 0.45% NACL INJECTION 5-450 24 X 500ML BAG ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5% AND 0.45% NACL INJECTION 5-450 24 X 500ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 5%-1/3NS IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5%-1/3NS IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 5%-1/4NS IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5%-1/4NS IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 5%-1/4NS IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5%-1/4NS IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 5%-ELECTROLYTE 75 ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5%-ELECTROLYTE 75.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE 5%-LR IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5%-LR IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DEXTROSE 5%-NS IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE 5%-NS IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE IN LACTATED RINGERS SOLUTION FOR INJECTION 1000ML PLASTIC BAG X 12 CASE ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE IN LACTATED RINGERS SOLUTION FOR INJECTION 1000ML PLASTIC BAG X 12 CASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE IN SODIUM CHLORIDE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE IN SODIUM CHLORIDE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE IN SODIUM CHLORIDE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE IN SODIUM CHLORIDE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE INJECTION 10 250ML X 24 BOTPL ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE INJECTION 10 250ML X 24 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSE INJECTION USP 5 4 X 100ML CTR ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSE INJECTION USP 5 4 X 100ML CTR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DEXTROSTAT 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSTAT 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DEXTROSTAT 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DEXTROSTAT 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIABETIC SUPPLIES, MISC 0 N/A INJC ![Compare how all Medicare Part D PDP plans in PA cover DIABETIC SUPPLIES, MISC 0 N/A INJC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DICLOFENAC 25MG TABLET EC ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC 25MG TABLET EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC POTASSIUM 50MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOFENAC SOD 100MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC SOD 100MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SOD 100MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC SOD 100MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOFENAC SODIUM 0.1% DROPS ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC SODIUM 0.1% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOXACILLIN 250MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DICLOXACILLIN 250MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICLOXACILLIN SODIUM 500MG CAP ![Compare how all Medicare Part D PDP plans in PA cover DICLOXACILLIN SODIUM 500MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICYCLOMINE 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DICYCLOMINE 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICYCLOMINE 10MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DICYCLOMINE 10MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DICYCLOMINE HCL 10MG/5ML SYRUP ![Compare how all Medicare Part D PDP plans in PA cover DICYCLOMINE HCL 10MG/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DICYCLOMINE HCL 20MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIDANOSINE 200MG CAPSULE DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DIDANOSINE 200MG CAPSULE DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIDANOSINE 250MG CAPSULE DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DIDANOSINE 250MG CAPSULE DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DIDANOSINE 400MG CAPSULE DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT ![Compare how all Medicare Part D PDP plans in PA cover DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIFLORASONE 0.05% CREAM ![Compare how all Medicare Part D PDP plans in PA cover DIFLORASONE 0.05% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIFLORASONE 0.05% OINTMENT ![Compare how all Medicare Part D PDP plans in PA cover DIFLORASONE 0.05% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIFLUCAN/DEXTRSE 0.4G/200ML ![Compare how all Medicare Part D PDP plans in PA cover DIFLUCAN/DEXTRSE 0.4G/200ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DIFLUCAN/DEXTRSE 200MG/100ML ![Compare how all Medicare Part D PDP plans in PA cover DIFLUCAN/DEXTRSE 200MG/100ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DIFLUNISAL 500MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIFLUNISAL 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIGITEK 125MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIGITEK 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIGITEK 250MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIGITEK 250MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGOXIN 125MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIGOXIN 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIGOXIN 250MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover DIGOXIN 250MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIGOXIN 50MCG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in PA cover DIGOXIN 50MCG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP ![Compare how all Medicare Part D PDP plans in PA cover DIGOXIN INJECTION 500MCG 25 X 2ML AMP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIHYDROERGOTAMINE 1MG/ML AM ![Compare how all Medicare Part D PDP plans in PA cover DIHYDROERGOTAMINE 1MG/ML AM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:10 /1Days |
DILANTIN 30MG KAPSEAL ![Compare how all Medicare Part D PDP plans in PA cover DILANTIN 30MG KAPSEAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DILANTIN 50MG INFATAB ![Compare how all Medicare Part D PDP plans in PA cover DILANTIN 50MG INFATAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DILANTIN-125 SUS 125/5ML ![Compare how all Medicare Part D PDP plans in PA cover DILANTIN-125 SUS 125/5ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DILAUDID 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILAUDID 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DILAUDID 4MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILAUDID 4MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILAUDID 8MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILAUDID 8MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DILAUDID-5 1MG/ML LIQUID ![Compare how all Medicare Part D PDP plans in PA cover DILAUDID-5 1MG/ML LIQUID.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DILT-CD 120MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in PA cover DILT-CD 120MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILT-CD 180MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in PA cover DILT-CD 180MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILT-CD 240MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in PA cover DILT-CD 240MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG ![Compare how all Medicare Part D PDP plans in PA cover DILT-CD DILTIAZEM HCL ER CAPSULES 300MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILT-XR 120MG CAPSULE DEGRADABLE CONTROLLED-RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DILT-XR 120MG CAPSULE DEGRADABLE CONTROLLED-RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM 30MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM 30MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM 90MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM 90MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM CD CAPSULES 120MG (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM CD CAPSULES 240MG (90 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM CD CAPSULES 240MG (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM CD CAPSULES 300MG (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 120MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 120MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 180MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 180MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 180MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 180MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 240MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 240MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 240MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 240MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 300MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 300MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 360MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 360MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM ER 420MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM ER 420MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 100MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 100MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 120MG ER CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 120MG ER CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 120MG ER CAPSULE (90 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 120MG ER CAPSULE (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 120MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 120MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 180MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 180MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 240MG ER CAPSULE (90 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 240MG ER CAPSULE (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 300MG ER CAPSULE (90 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 300MG ER CAPSULE (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 360MG ER CAPSULE (30 CT) ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 360MG ER CAPSULE (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 60MG ER CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 60MG ER CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 60MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 60MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL 90MG ER CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL 90MG ER CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTIAZEM HCL INJECTION 5MG 10 5ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover DILTIAZEM HCL INJECTION 5MG 10 5ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG ![Compare how all Medicare Part D PDP plans in PA cover DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG ![Compare how all Medicare Part D PDP plans in PA cover DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG ![Compare how all Medicare Part D PDP plans in PA cover DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG ![Compare how all Medicare Part D PDP plans in PA cover DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DILTZAC ER CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DILTZAC ER CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIOVAN 160MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN 160MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN 320MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN 320MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN 40MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN 80MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN HCT 160/12.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN HCT 160/12.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN HCT 160/25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN HCT 160/25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN HCT 320/12.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN HCT 320/12.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN HCT 320/25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN HCT 320/25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIOVAN HCT 80/12.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DIOVAN HCT 80/12.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DIPHENHYDRAMINE 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DIPHENHYDRAMINE 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPHENHYDRAMINE 50MG CAPS ![Compare how all Medicare Part D PDP plans in PA cover DIPHENHYDRAMINE 50MG CAPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DIPHENHYDRAMINE ELIXIR BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover DIPHENHYDRAMINE ELIXIR BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL ![Compare how all Medicare Part D PDP plans in PA cover DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPHENOXYLATE/ATROPINE LIQ ![Compare how all Medicare Part D PDP plans in PA cover DIPHENOXYLATE/ATROPINE LIQ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF ![Compare how all Medicare Part D PDP plans in PA cover DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIPIVEFRIN 0.1% EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover DIPIVEFRIN 0.1% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPYRIDAMOLE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DIPYRIDAMOLE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPYRIDAMOLE 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DIPYRIDAMOLE 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIPYRIDAMOLE 75MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DIPYRIDAMOLE 75MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DISOPYRAMIDE 150MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover DISOPYRAMIDE 150MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIURIL SODIUM 500MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DIURIL SODIUM 500MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DIVALPROEX SODIUM 125MG TBEC ![Compare how all Medicare Part D PDP plans in PA cover DIVALPROEX SODIUM 125MG TBEC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIVALPROEX SODIUM 250MG TBEC ![Compare how all Medicare Part D PDP plans in PA cover DIVALPROEX SODIUM 250MG TBEC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIVALPROEX SODIUM 500MG TBEC ![Compare how all Medicare Part D PDP plans in PA cover DIVALPROEX SODIUM 500MG TBEC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT ![Compare how all Medicare Part D PDP plans in PA cover DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT ![Compare how all Medicare Part D PDP plans in PA cover DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT ![Compare how all Medicare Part D PDP plans in PA cover DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DIVIGEL 0.25(0.1%) GEL IN PACKET ![Compare how all Medicare Part D PDP plans in PA cover DIVIGEL 0.25(0.1%) GEL IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DIVIGEL 0.5MG(0.1) GEL IN PACKET ![Compare how all Medicare Part D PDP plans in PA cover DIVIGEL 0.5MG(0.1) GEL IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DIVIGEL 1MG(0.1%) GEL IN PACKET ![Compare how all Medicare Part D PDP plans in PA cover DIVIGEL 1MG(0.1%) GEL IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DOLOREX FORTE 5MG-500MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOLOREX FORTE 5MG-500MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DORIBAX INJECTION ![Compare how all Medicare Part D PDP plans in PA cover DORIBAX INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | None |
DORYX 100MG TABLET DR ![Compare how all Medicare Part D PDP plans in PA cover DORYX 100MG TABLET DR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DORYX 75MG TABLET DR ![Compare how all Medicare Part D PDP plans in PA cover DORYX 75MG TABLET DR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DORYX DELAYED RELEASE TABLETS 150MG ![Compare how all Medicare Part D PDP plans in PA cover DORYX DELAYED RELEASE TABLETS 150MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR ![Compare how all Medicare Part D PDP plans in PA cover DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML; ![Compare how all Medicare Part D PDP plans in PA cover DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML;.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOVONEX 0.005% CREAM ![Compare how all Medicare Part D PDP plans in PA cover DOVONEX 0.005% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOVONEX 0.005% SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover DOVONEX 0.005% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXAZOSIN MESYLATE TABLET 2MG (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXAZOSIN MESYLATE TABLET 2MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXAZOSIN MESYLATE TABLET 4MG (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXAZOSIN MESYLATE TABLET 4MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXAZOSIN MESYLATE TABLET 8MG (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXAZOSIN MESYLATE TABLET 8MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXAZOSIN TABLET 1MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXAZOSIN TABLET 1MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXEPIN 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXEPIN 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXEPIN 10MG/ML ORAL CONC ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN 10MG/ML ORAL CONC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXEPIN 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN HCL 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXEPIN HCL 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXEPIN HCL 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | None |
DOXIL INJECTION 2MG ![Compare how all Medicare Part D PDP plans in PA cover DOXIL INJECTION 2MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
DOXORUBICIN 10MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DOXORUBICIN 10MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
DOXORUBICIN 50MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DOXORUBICIN 50MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD ![Compare how all Medicare Part D PDP plans in PA cover DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD ![Compare how all Medicare Part D PDP plans in PA cover DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | P |
DOXYCYCLINE 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE 100MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE 100MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE HYCLATE 20MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE HYCLATE 75MG CAPSULE DELAYED RELEASE (60 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE HYCLATE 75MG CAPSULE DELAYED RELEASE (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE MONO 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE MONO 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE MONO 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE MONO 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE MONOHYDRATE 25MG/5ML SUSR ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE MONOHYDRATE 25MG/5ML SUSR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE MONOHYDRATE 75MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE TABLET 100MG (250 CT) ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE TABLET 100MG (250 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DOXYCYCLINE TABLETS 150MG 30 BOT ![Compare how all Medicare Part D PDP plans in PA cover DOXYCYCLINE TABLETS 150MG 30 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL CAPS 10MG ![Compare how all Medicare Part D PDP plans in PA cover DRONABINOL CAPS 10MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
DRONABINOL CAPS 2.5MG ![Compare how all Medicare Part D PDP plans in PA cover DRONABINOL CAPS 2.5MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | P |
DRONABINOL CAPS 5MG ![Compare how all Medicare Part D PDP plans in PA cover DRONABINOL CAPS 5MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | 25% | P |
DROXIA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DROXIA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DROXIA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DROXIA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DROXIA 400MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DROXIA 400MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DTIC-DOME IV 200MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover DTIC-DOME IV 200MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DUETACT 30MG-2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DUETACT 30MG-2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DUETACT 30MG-4MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover DUETACT 30MG-4MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
DURAMORPH 0.5MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in PA cover DURAMORPH 0.5MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
DURAMORPH 1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in PA cover DURAMORPH 1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$2.50 | $6.25 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYGASE 30-2.4-30 CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover DYGASE 30-2.4-30 CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
DYNACIRC CR 10MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover DYNACIRC CR 10MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |
DYNACIRC CR 5MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover DYNACIRC CR 5MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$94.00 | $235.00 | None |