2009 Medicare Part D Plan Formulary Information |
HealthSpring Prescription Drug Plan -Reg 5 (S5932-034-0)
Benefit Details
|
The HealthSpring Prescription Drug Plan -Reg 5 (S5932-034-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 5 which includes: DC DE MD
|
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 |
D5-1/2NS/KCL 30MEQ/L IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
D5W/KCL 20MEQ/L IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
D5W/KCL 30MEQ/L IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
DACARBAZINE 100MG VIAL |
2 |
Tier 2 |
25% | 25% | P |
DACARBAZINE 200MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
DACOGEN INJ 50MG |
2 |
Tier 2 |
25% | 25% | P |
DANAZOL 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DANAZOL 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DANTROLENE SODIUM 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTROLENE SODIUM 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DANTROLENE SODIUM 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DAPSONE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DAPSONE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
2 |
Tier 2 |
25% | 25% | P |
DARAPRIM 25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DAUNORUBICIN 5MG/ML VIAL |
2 |
Tier 2 |
25% | 25% | P |
DAUNORUBICIN HCL POWDER FOR INJECTION USP 20MG 1 VIALSD |
1 |
Tier 1 |
25% | 25% | P |
DAUNOXOME 2MG/ML VIAL |
2 |
Tier 2 |
25% | 25% | P |
DECAVAC VACCINE 2;5 UNT/0.5 ML |
2 |
Tier 2 |
25% | 25% | P |
DECLOMYCIN 150MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DECLOMYCIN 300MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DEL-BETA 0.05% LOTION |
1 |
Tier 1 |
25% | 25% | None |
DEMADEX 10MG/ML AMPUL |
2 |
Tier 2 |
25% | 25% | None |
DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DENAVIR 1% CREAM |
2 |
Tier 2 |
25% | 25% | None |
DEPADE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEPAKOTE 125MG SPRINKLE CAP |
2 |
Tier 2 |
25% | 25% | None |
DEPAKOTE 125MG TABLET EC |
2 |
Tier 2 |
25% | 25% | None |
DEPAKOTE 250MG TABLET EC |
2 |
Tier 2 |
25% | 25% | None |
DEPAKOTE 500MG TABLET EC |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPAKOTE ER 250MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
DEPAKOTE ER 500MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DEPEN 250MG TITRATAB |
2 |
Tier 2 |
25% | 25% | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
2 |
Tier 2 |
25% | 25% | None |
DEPO-MEDROL 20MG/ML VIAL |
2 |
Tier 2 |
25% | 25% | None |
DEPO-TESTOSTERONE 100MG/ML |
2 |
Tier 2 |
25% | 25% | None |
DEPO-TESTOSTERONE 200MG/ML |
2 |
Tier 2 |
25% | 25% | None |
DERMOTIC 0.01% DROPS |
2 |
Tier 2 |
25% | 25% | None |
DESIPRAMINE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DESIPRAMINE 150MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DESIPRAMINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DESIPRAMINE HCL TABLET 100MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
DESMOPRESSIN 0.1MG/ML SOL |
1 |
Tier 1 |
25% | 25% | None |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Tier 1 |
25% | 25% | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DESONIDE 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
DESONIDE 0.05% LOTION |
1 |
Tier 1 |
25% | 25% | None |
DESONIDE 0.05% OINTMENT 60GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
DESOXIMETASONE 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOXIMETASONE 0.05% GEL |
1 |
Tier 1 |
25% | 25% | None |
DESOXIMETASONE 0.25% CREAM |
1 |
Tier 1 |
25% | 25% | None |
DESOXIMETASONE 0.25% OINT |
1 |
Tier 1 |
25% | 25% | None |
DETROL 1MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DETROL 2MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DETROL LA 2MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | None |
DETROL LA 4MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 0.5MG/5ML LIQ |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.75MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 1MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 2MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 4MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE 6MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Tier 1 |
25% | 25% | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Tier 1 |
25% | 25% | None |
DEXASPORIN EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXPAK 1.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DEXRAZOXANE 250MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
DEXRAZOXANE 500MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
DEXTROAMPHETAMINE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DEXTROAMPHETAMINE SACCHARATE AMPHETAMINE ASPARATE |
1 |
Tier 1 |
25% | 25% | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DEXTROAMPHETAMINE SULFATE 10MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DEXTROAMPHETAMINE SULFATE 15MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DEXTROAMPHETAMINE SULFATE 5MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE 5% AND 0.45% NACL INJECTION 5-450 24 X 500ML BAG |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE 5%-1/3NS IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE 5%-1/4NS IV SOLUTION |
2 |
Tier 2 |
25% | 25% | P |
DEXTROSE 5%-ELECTROLYTE 75 |
1 |
Tier 1 |
25% | 25% | None |
DEXTROSE 5%-LR IV SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
DEXTROSE 5%-NS IV SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE IN LACTATED RINGERS SOLUTION FOR INJECTION 1000ML PLASTIC BAG X 12 CASE |
1 |
Tier 1 |
25% | 25% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2 |
Tier 2 |
25% | 25% | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Tier 1 |
25% | 25% | P |
DEXTROSTAT 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DIABETIC SUPPLIES, MISC 0 N/A INJC |
1 |
Tier 1 |
25% | 25% | None |
DIBENZYLINE 10MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC 25MG TABLET EC |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC SOD 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC SOD 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Tier 1 |
25% | 25% | None |
DICYCLOMINE 10MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE 10MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Tier 1 |
25% | 25% | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
DIDANOSINE 200MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DIDANOSINE 250MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DIFLORASONE 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
DIFLORASONE 0.05% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
DIFLUNISAL 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DIGITEK 125MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DIGITEK 250MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGOXIN 125MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DIGOXIN 250MCG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Tier 1 |
25% | 25% | None |
DIHYDROERGOTAMINE 1MG/ML AM |
1 |
Tier 1 |
25% | 25% | None |
DILANTIN 30MG KAPSEAL |
2 |
Tier 2 |
25% | 25% | None |
DILANTIN 50MG INFATAB |
2 |
Tier 2 |
25% | 25% | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
DILANTIN-125 SUS 125/5ML |
2 |
Tier 2 |
25% | 25% | None |
DILAUDID-5 1MG/ML LIQUID |
2 |
Tier 2 |
25% | 25% | Q:1200 /30Days |
DILAUDID-HP 250MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
DILT-CD 120MG CAPSULE SR 24 HR |
1 |
Tier 1 |
25% | 25% | 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 |
1 |
Tier 1 |
25% | 25% | None |
DILT-CD 240MG CAPSULE SR 24 HR |
1 |
Tier 1 |
25% | 25% | None |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Tier 1 |
25% | 25% | None |
DILT-XR 120MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM 30MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM 90MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 120MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM ER 180MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 180MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 300MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 360MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM ER 420MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 100MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 120MG ER CAPSULE (90 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 180MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 240MG ER CAPSULE (90 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 300MG ER CAPSULE (90 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 360MG ER CAPSULE (30 CT) |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL 90MG ER CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DILTIAZEM HCL INJECTION 5MG 10 5ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
DIOVAN 160MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN 320MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN 40MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN 80MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN HCT 160/12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN HCT 160/25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN HCT 320/12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN HCT 320/25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIOVAN HCT 80/12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DIPHENHYDRAMINE 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DIPHENHYDRAMINE 50MG CAPS |
1 |
Tier 1 |
25% | 25% | None |
DIPHENHYDRAMINE ELIXIR BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPHENOXYLATE/ATROPINE LIQ |
1 |
Tier 1 |
25% | 25% | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
2 |
Tier 2 |
25% | 25% | P |
DIPIVEFRIN 0.1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
DIPYRIDAMOLE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DIPYRIDAMOLE 50MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DIPYRIDAMOLE 75MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DISOPYRAMIDE 150MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DIURIL SODIUM 500MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM 250MG TBEC |
1 |
Tier 1 |
25% | 25% | None |
DIVALPROEX SODIUM 500MG TBEC |
1 |
Tier 1 |
25% | 25% | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
DOLOREX FORTE 5MG-500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
DORIBAX INJECTION |
2 |
Tier 2 |
25% | 25% | None |
DOVONEX 0.005% CREAM |
2 |
Tier 2 |
25% | 25% | None |
DOVONEX 0.005% SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
DOXAZOSIN MESYLATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXAZOSIN MESYLATE TABLET 4MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXAZOSIN MESYLATE TABLET 8MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN 10MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN 150MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN 75MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXEPIN HCL 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXIL INJECTION 2MG |
2 |
Tier 2 |
25% | 25% | P |
DOXORUBICIN 10MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
DOXORUBICIN 50MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD |
1 |
Tier 1 |
25% | 25% | P |
DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD |
1 |
Tier 1 |
25% | 25% | P |
DOXYCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE 100MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE MONO 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE MONO 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE TABLET 100MG (250 CT) |
1 |
Tier 1 |
25% | 25% | None |
DROXIA 200MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
DROXIA 300MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
DROXIA 400MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
DUETACT 30MG-2MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DUETACT 30MG-4MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
DURAMORPH 0.5MG/ML AMPUL |
1 |
Tier 1 |
25% | 25% | None |
DURAMORPH 1MG/ML AMPUL |
1 |
Tier 1 |
25% | 25% | None |
DYGASE 30-2.4-30 CAPSULE |
2 |
Tier 2 |
25% | 25% | None |