2010 Medicare Part D Plan Formulary Information |
MediBlue Value (PPO) (H3342-012-0)
Benefit Details
|
The MediBlue Value (PPO) (H3342-012-0) Formulary Drugs Starting with the Letter D in Rockl County, NY: CMS MA Region 3 which includes: NY
|
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 |
4 |
Tier 4 |
33% | 33% | None |
D5W/KCL 20MEQ/L IV SOLUTION |
4 |
Tier 4 |
33% | 33% | None |
D5W/KCL 30MEQ/L IV SOLUTION |
4 |
Tier 4 |
33% | 33% | None |
DACARBAZINE 200MG VIAL |
4 |
Tier 4 |
33% | 33% | P |
DACOGEN INJ 50MG |
5 |
Tier 5 |
33% | N/A | P |
DANAZOL 100MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DANAZOL 50MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DANTRIUM 100MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DANTRIUM 25MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTRIUM 50MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DAPSONE TABLETS 100MG 30 BLPK |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DAPSONE TABLETS 25MG 30 BLPK |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DARAPRIM 25MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DARVOCET A500 100-500MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:240 /30Days |
DARVOCET-N 100 100-650MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:180 /30Days |
DARVOCET-N 50 50MG-325MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DARVON CAPSULES 65MG (100 CT) |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DARVON-N 100MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DAUNORUBICIN 5MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
DAUNOXOME 2MG/ML VIAL |
5 |
Tier 5 |
33% | N/A | None |
DAYPRO 600MG CAPLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DDAVP 0.01% NASAL SPRAY |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DDAVP 0.1MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DDAVP 0.2MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DDAVP 4MCG/ML AMPUL |
4 |
Tier 4 |
33% | 33% | None |
DECAVAC VACCINE 2;5 UNT/0.5 ML |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DECLOMYCIN 150MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:84 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DECLOMYCIN 300MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:42 /1Days |
DEGARELIX INJ |
5 |
Tier 5 |
33% | N/A | None |
DEGARELIX SOLR |
4 |
Tier 4 |
33% | 33% | None |
DEL-BETA 0.05% LOTION |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DELESTROGEN 40MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
4 |
Tier 4 |
33% | 33% | None |
DELESTROGEN INJECTION 20MG/5ML VIALMD |
4 |
Tier 4 |
33% | 33% | None |
DEMADEX 10MG/ML AMPUL |
4 |
Tier 4 |
33% | 33% | None |
DEMADEX TABLETS 10MG 10 GM BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEMADEX TABLETS 20MG 20 MG BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEMADEX TBALETS 5MG 5 MG BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | Q:84 /1Days |
DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | Q:42 /1Days |
DEMEROL 100MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEMEROL 100MG/ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
DEMEROL 25MG/ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
DEMEROL 50MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEMEROL 50MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
DEMEROL 75MG/ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
DEMSER CAPSULES 250MG (100 CT) |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DENAVIR 1% CREAM |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DEPACON INJ 100MG/ML |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPADE 50MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEPAKENE 250MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEPAKENE 250MG/5ML SYRUP |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEPAKOTE 125MG SPRINKLE CAP |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DEPAKOTE 125MG TABLET EC |
2 |
Tier 2 |
$42.00 | $84.00 | Q:60 /30Days |
DEPAKOTE 250MG TABLET EC |
2 |
Tier 2 |
$42.00 | $84.00 | Q:90 /30Days |
DEPAKOTE 500MG TABLET EC |
2 |
Tier 2 |
$42.00 | $84.00 | Q:300 /30Days |
DEPAKOTE ER 250MG TABLET SA |
2 |
Tier 2 |
$42.00 | $84.00 | Q:60 /30Days |
DEPAKOTE ER 500MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | Q:300 /30Days |
DEPEN 250MG TITRATAB |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-MEDROL 20MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DEPO-MEDROL 40MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DEPO-MEDROL 80MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DEPO-PROVERA 150MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DEPO-SQ PROV INJ 104 |
4 |
Tier 4 |
33% | 33% | None |
DEPO-TESTOSTERONE 100MG/ML |
4 |
Tier 4 |
33% | 33% | None |
DEPO-TESTOSTERONE 200MG/ML |
4 |
Tier 4 |
33% | 33% | None |
DERMA-SMOOTHE/FS 0.01% BODY OIL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DERMATOP 0.1% CREAM |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DERMATOP 0.1% OINTMENT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DERMOTIC 0.01% DROPS |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DESIPRAMINE 25MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESIPRAMINE 50MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS 150MG 50 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESMOPRESSIN 0.1MG/ML SOL |
1 |
Tier 1 |
$7.00 | $14.00 | Q:15 /30Days |
DESMOPRESSIN AC 4MCG/ML VL |
4 |
Tier 4 |
33% | 33% | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
1 |
Tier 1 |
$7.00 | $14.00 | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESOGEN 28 DAY TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:28 /28Days |
DESONIDE 0.05% CREAM |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESONIDE 0.05% LOTION |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESONIDE 0.05% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESOXIMETASONE 0.05% CREAM |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESOXIMETASONE 0.05% GEL |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESOXIMETASONE 0.25% CREAM |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DESOXIMETASONE 0.25% OINT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DETROL 1MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DETROL 2MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DETROL LA 2MG CAPSULE SA |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DETROL LA 4MG CAPSULE SA |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 1MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 2MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
4 |
Tier 4 |
33% | 33% | None |
DEXASPORIN EYE DROPS |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXCHLORPHEN 2MG/5ML SYRUP |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXEDRINE D-AMPHETAMINE SULFATE 10MG CAPSULE SA ORAL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEXEDRINE D-AMPHETAMINE SULFATE 15MG CAPSULE SA ORAL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEXEDRINE SPANSULE 5MG 90 EA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | Q:120 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | Q:60 /30Days |
DEXPAK 1.5MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXRAZOXANE 500MG VIAL |
5 |
Tier 5 |
33% | N/A | None |
DEXTROAMPHETAMINE 10MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DEXTROSE 10%-1/4NS IV TUBEX |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
4 |
Tier 4 |
33% | 33% | 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 |
Tier 4 |
33% | 33% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
4 |
Tier 4 |
33% | 33% | None |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
4 |
Tier 4 |
33% | 33% | None |
DIABETA 1.25MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIABETA TABLETS 2.5MG 100 BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIABETA TABLETS 5MG 1000 BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIAMOX SEQUELS 500MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIBENZYLINE 10MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DICLOFENAC 25MG TABLET EC |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOFENAC SOD 100MG TABLET SA |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICYCLOMINE 10MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICYCLOMINE 10MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIDANOSINE 200MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIDANOSINE 250MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIDRONEL 200MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIDRONEL 400MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFFERIN 0.1% CREAM |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFFERIN 0.1% GEL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFFERIN 0.3% GEL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLORASONE 0.05% CREAM |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIFLORASONE 0.05% OINTMENT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIFLUCAN 100MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFLUCAN 150MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFLUCAN 200MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFLUCAN 200MG/5ML SUSPEN |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFLUCAN 50MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFLUCAN 50MG/5ML SUSPEN |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIFLUCAN INJECTION 200MG 100ML BOT |
4 |
Tier 4 |
33% | 33% | None |
DIFLUNISAL 500MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIGOXIN 125MCG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGOXIN 250MCG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIGOXIN 50MCG/ML SOLUTION ORAL |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
4 |
Tier 4 |
33% | 33% | None |
DIHYDROERGOTAMINE 1MG/ML AM |
4 |
Tier 4 |
33% | 33% | None |
DILACOR XR 120MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILACOR XR 180MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILACOR XR 240MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILANTIN 30MG KAPSEAL |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DILANTIN 50MG INFATAB |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DILANTIN-125 SUS 125/5ML |
2 |
Tier 2 |
$42.00 | $84.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILATRATE-SR 40MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILAUDID HP HYDROMORPHONE HCL INJECTION 10MG/ML ML VIALSD |
4 |
Tier 4 |
33% | 33% | P |
DILAUDID HYDROMORPHONE HCL INJECTION 2MG/ML 10 AMP BOX |
4 |
Tier 4 |
33% | 33% | None |
DILAUDID HYDROMORPHONE HCL INJECTION 4MG/ML 10 AMP BOX |
4 |
Tier 4 |
33% | 33% | None |
DILAUDID HYDROMORPHONE HCL ORAL LIQUID 1MG/ML 1 PINT BOTGL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 2MG 100 TABS BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 4MG 100 TAB BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 8MG 100 TAB BOT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DILAUDID HYDROMORPHONE HYDROCHLORIDE INJECTION 1MG/ML 10 AMPULES BOX |
4 |
Tier 4 |
33% | 33% | None |
DILT-CD 120MG CAPSULE SR 24 HR |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILT-CD 180MG CAPSULE SR 24 HR |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM 30MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM 90MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM ER 360MG CAPSULE SA |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM ER 420MG CAPSULE SA |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM HCL 100MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTIAZEM HCL INJECTION 5MG 10 5ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES USP 90MG 1 BLPK |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DILTZAC ER CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN 160MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN 320MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN 40MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN 80MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN HCT 160/12.5MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN HCT 160/25MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN HCT 320/12.5MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN HCT 320/25MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIOVAN HCT 80/12.5MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIPENTUM 250MG CAPSULE 125EA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIPHENHYDRAMINE 25MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPHENHYDRAMINE 50MG CAPS |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIPHENHYDRAMINE HCL ELIXIR 12.5MG/5ML 20 ML PKG |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL |
4 |
Tier 4 |
33% | 33% | None |
DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
2 |
Tier 2 |
$42.00 | $84.00 | None |
DIPIVEFRIN 0.1% EYE DROPS |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIPROLENE 0.05% LOTION |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIPROLENE 0.05% OINTMENT |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIPROLENE AF 0.05% CREAM |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIPYRIDAMOLE TABETS 25MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPYRIDAMOLE TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIPYRIDAMOLE TABLETS 75MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DITROPAN XL EXTENDED RELEASE TABLETS 5MG |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DITROPAN XL TABLETS 10MG |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DITROPAN XL TABLETS 15MG |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DIURIL SODIUM 500MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Tier 1 |
$7.00 | $14.00 | Q:60 /30Days |
DIVALPROEX SODIUM 250MG TBEC |
1 |
Tier 1 |
$7.00 | $14.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM 500MG TBEC |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | Q:60 /30Days |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOLOPHINE HCL 10MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DOLOPHINE HCL 5MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DORIBAX INJECTION |
5 |
Tier 5 |
33% | N/A | None |
DORYX 100MG TABLET DR |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DORYX 75MG TABLET DR |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DORYX DELAYED RELEASE TABLETS 150MG |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Tier 1 |
$7.00 | $14.00 | Q:20 /30Days |
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; |
1 |
Tier 1 |
$7.00 | $14.00 | Q:20 /30Days |
DOVONEX 0.005% CREAM |
2 |
Tier 2 |
$42.00 | $84.00 | Q:200 /30Days |
DOVONEX 0.005% SOLUTION |
3 |
Tier 3 |
$80.00 | $160.00 | Q:60 /30Days |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXAZOSIN MESYLATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXAZOSIN MESYLATE TABLET 8MG (500 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXEPIN 10MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXEPIN 150MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXEPIN 50MG CAPSULE 100 EA |
1 |
Tier 1 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 75MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXIL INJECTION 2MG |
4 |
Tier 4 |
33% | 33% | P |
DOXORUBICIN 50MG VIAL |
4 |
Tier 4 |
33% | 33% | P |
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD |
4 |
Tier 4 |
33% | 33% | P |
DOXYCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE 100MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE HYCLATE 75MG CAPSULE DELAYED RELEASE (60 CT) |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE MONOHYDRATE 25MG/5ML SUSR |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
1 |
Tier 1 |
$7.00 | $14.00 | None |
DRONABINOL CAPS 10MG |
1 |
Tier 1 |
$7.00 | $14.00 | P |
DRONABINOL CAPS 2.5MG |
1 |
Tier 1 |
$7.00 | $14.00 | P |
DRONABINOL CAPS 5MG |
1 |
Tier 1 |
$7.00 | $14.00 | P |
DROXIA 200MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DROXIA 300MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DROXIA 400MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DUETACT 30MG-2MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | Q:30 /30Days |
DUETACT 30MG-4MG TABLET |
2 |
Tier 2 |
$42.00 | $84.00 | Q:30 /30Days |
DUONEB INHALATION SOLUTION 3-.5MG 60 X 3ML CRTN |
3 |
Tier 3 |
$80.00 | $160.00 | P |
DURAGESIC 100MCG/HR PATCH |
3 |
Tier 3 |
$80.00 | $160.00 | Q:15 /30Days |
DURAGESIC 12 MCG/HR PATCH |
3 |
Tier 3 |
$80.00 | $160.00 | Q:15 /30Days |
DURAGESIC 25MCG/HR PATCH |
3 |
Tier 3 |
$80.00 | $160.00 | Q:15 /30Days |
DURAGESIC 50MCG/HR PATCH |
3 |
Tier 3 |
$80.00 | $160.00 | Q:15 /30Days |
DURAGESIC 75MCG/HR PATCH |
3 |
Tier 3 |
$80.00 | $160.00 | Q:15 /30Days |
DURAMORPH 0.5MG/ML AMPUL |
4 |
Tier 4 |
33% | 33% | P |
DURAMORPH 1MG/ML AMPUL |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYAZIDE 37.5/25 CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DYNACIN 50MG TABLET |
3 |
Tier 3 |
$80.00 | $160.00 | Q:60 /1Days |
DYNACIN MINOCYCLINE HCL TABLETS 100MG 50 BOT |
3 |
Tier 3 |
$80.00 | $160.00 | Q:60 /1Days |
DYNACIN MINOCYCLINE HCL TABLETS 75MG 100 BOT |
3 |
Tier 3 |
$80.00 | $160.00 | Q:60 /1Days |
DYNACIRC CR 10MG TABLET SA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DYNACIRC CR 5MG TABLET SA |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DYRENIUM 100MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |
DYRENIUM 50MG CAPSULE |
3 |
Tier 3 |
$80.00 | $160.00 | None |