2011 Medicare Part D Plan Formulary Information |
Presbyterian MediCare PPO Plan 3 with Rx (PPO) (H3206-002-0)
Benefit Details
|
The Presbyterian MediCare PPO Plan 3 with Rx (PPO) (H3206-002-0) Formulary Drugs Starting with the Letter D in Mora County, NM: CMS MA Region 20 which includes: NM
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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 |
DACOGEN FOR INJECTION |
4 |
Tier 4 |
30% | N/A | P |
DANAZOL 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DANAZOL 50MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DAPSONE TABLETS 25MG 30 BLPK |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DARAPRIM 25MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DAUNOXOME INJECTION |
4 |
Tier 4 |
30% | N/A | None |
DECAVAC VACCINE 2;5 UNT/0.5 ML |
2 |
Tier 2 |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEGARELIX INJ |
4 |
Tier 4 |
30% | N/A | None |
DEGARELIX SOLR |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DENAVIR 1% CREAM |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DEPACON INJ 100MG/ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKENE 250MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKENE 250MG/5ML SYRUP |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKOTE 125MG SPRINKLE CAP |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKOTE 125MG TABLET EC |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKOTE 250MG TABLET EC |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKOTE 500MG TABLET EC |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPAKOTE ER 250MG TABLET SA |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPAKOTE ER 500MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DERMOTIC 0.01% DROPS |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DESIPRAMINE 25MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESIPRAMINE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESMOPRESSIN 0.1MG/ML SOL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESONIDE 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESONIDE 0.05% LOTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESONIDE 0.05% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESOXIMETASONE 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESOXIMETASONE 0.05% GEL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESOXIMETASONE 0.25% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DESOXIMETASONE 0.25% OINT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DETROL 1MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S |
DETROL 2MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DETROL LA 2MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | S |
DETROL LA 4MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | S |
DEXAMETHASONE 0.5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXAMETHASONE 1MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DEXAMETHASONE 2MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMPHETAMINE 10MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:60 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Tier 1 |
$5.00 | $10.00 | S |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
1 |
Tier 1 |
$5.00 | $10.00 | S |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
1 |
Tier 1 |
$5.00 | $10.00 | S |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOFENAC 25MG TABLET EC |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOFENAC SOD 100MG TABLET SA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE 10MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICYCLOMINE 10MG/ML VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIDANOSINE 200MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIDANOSINE 250MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIFFERIN 0.1% CREAM |
2 |
Tier 2 |
$40.00 | $100.00 | P |
DIFFERIN 0.1% GEL |
2 |
Tier 2 |
$40.00 | $100.00 | P |
DIFLORASONE 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLORASONE 0.05% OINTMENT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIFLUCAN INJECTION |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DIGOXIN 125MCG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIGOXIN 250MCG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIGOXIN 50MCG/ML SOLUTION ORAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DIHYDROERGOTAMINE 1MG/ML AM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILANTIN 50MG INFATAB |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DILANTIN CAPSULES EXTENDED RELEASE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DILANTIN-125 SUS 125/5ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DILAUDID HYDROMORPHONE HCL ORAL LIQUID 1MG/ML 1 PINT BOTGL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 30MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM 90MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM ER 420MG CAPSULE SA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES USP 90MG 1 BLPK |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HYDROCHLORIDE INJECTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIOVAN 160MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN 320MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN 40MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN 80MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN HCT 160/12.5MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN HCT 160/25MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN HCT 320/12.5MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN HCT 320/25MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIOVAN HCT 80/12.5MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DIPHENHYDRAMINE 50MG CAPS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPHENOXYLATE/ATROPINE LIQ |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DIPYRIDAMOLE TABETS 25MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIPYRIDAMOLE TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIPYRIDAMOLE TABLETS 75MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIVALPROEX SODIUM 250MG TBEC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIVALPROEX SODIUM 500MG TBEC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | 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 |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DIVIGEL 1MG(0.1%) GEL IN PACKET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | Q:60 /30Days |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | Q:60 /30Days |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML; |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOVONEX CREAM |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXAZOSIN MESYLATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXAZOSIN MESYLATE TABLET 8MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXEPIN 10MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXEPIN 50 MG ORAL CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXEPIN 75MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
DOXYCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE 100MG VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
DRONABINOL CAPS 10MG |
3 |
Tier 3 |
$75.00 | $225.00 | P Q:60 /30Days |
DRONABINOL CAPS 2.5MG |
3 |
Tier 3 |
$75.00 | $225.00 | P Q:240 /30Days |
DRONABINOL CAPS 5MG |
3 |
Tier 3 |
$75.00 | $225.00 | P Q:120 /30Days |
DUETACT 30MG-2MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DUETACT 30MG-4MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | S |
DYRENIUM 100MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
DYRENIUM 50MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | None |