2011 Medicare Part D Plan Formulary Information |
FreedomBlue PPO HD (PPO) (H5106-026-0)
Benefit Details
|
The FreedomBlue PPO HD (PPO) (H5106-026-0) Formulary Drugs Starting with the Letter D in Harrison County, WV: CMS MA Region 6 which includes: 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 |
4 |
Tier 4 |
33% | 33% | None |
D5W/KCL 20MEQ/L IV SOLUTION |
2 |
Tier 2 |
$45.00 | $112.50 | None |
D5W/KCL 30MEQ/L IV SOLUTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DACARBAZINE 200MG VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DACOGEN FOR INJECTION |
4 |
Tier 4 |
33% | 33% | None |
DANAZOL 100MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DANAZOL 50MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DANTRIUM 100MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DANTRIUM 25 MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTRIUM 50 MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DAPSONE TABLETS 25MG 30 BLPK |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DARAPRIM 25MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DAUNORUBICIN HYDROCHLORIDE POWDER FOR INJECTION USP |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DAUNOXOME INJECTION |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DAYPRO 600MG CAPLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAYTRANA 10MG/9 HR PATCH |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DAYTRANA 15MG/9 HR PATCH |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DAYTRANA ER PATCH 55MG 30 CRTN |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DDAVP 0.01% NASAL SPRAY |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DDAVP 0.1MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DDAVP 0.2MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DDAVP 4MCG/ML AMPUL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DDAVP SOLUTION INTRANASAL 0.1MG/ML 2.5 ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DECAVAC VACCINE 2;5 UNT/0.5 ML |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEGARELIX INJ |
4 |
Tier 4 |
33% | 33% | None |
DEGARELIX SOLR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DELATESTRYL 200 MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | P |
DELESTROGEN 40 MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DELESTROGEN INJECTION 20MG/5ML VIALMD |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMADEX TABLETS 10MG 10 GM BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMADEX TABLETS 20MG 20 MG BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMADEX TBALETS 5MG 5 MG BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEMEROL 100MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMEROL 25MG/ML SYRINGE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEMEROL 50MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMEROL 50MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMEROL INJECTION 75MG/ML |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DENAVIR 1% CREAM |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEPACON INJ 100MG/ML |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPADE 50MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEPAKENE 250MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPAKENE 250MG/5ML SYRUP |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPAKOTE 125MG SPRINKLE CAP |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPAKOTE 125MG TABLET EC |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPAKOTE 250MG TABLET EC |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPAKOTE 500MG TABLET EC |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPAKOTE ER 250MG TABLET SA |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPAKOTE ER 500MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPEN 250MG TITRATAB |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPO-MEDROL 20MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPO-MEDROL 40MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPO-MEDROL 80MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPO-PROVERA 150MG/ML VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
2 |
Tier 2 |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-SUBQ PRO 104 MG PFS 0.65 ML |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEPO-TESTOSTERONE 100MG/ML |
3 |
Tier 3 |
$90.00 | $225.00 | P |
DEPO-TESTOSTERONE 200MG/ML |
3 |
Tier 3 |
$90.00 | $225.00 | P |
DERMA-SMOOTHE/FS 0.01% BODY OIL |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DERMATOP 0.1% CREAM |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DERMATOP 0.1% OINTMENT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DERMOTIC 0.01% DROPS |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DESIPRAMINE 25MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESIPRAMINE 50MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESMOPRESSIN 0.1MG/ML SOL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESOGEN 28 DAY TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DESONATE GEL 0.05% |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DESONIDE 0.05% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESONIDE 0.05% LOTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONIDE 0.05% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESOWEN CREAM 0.05% 60GM TUBE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DESOWEN LOTION 0.05% 1X4 FL OZ PKGCOM |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DESOWEN OINTMENT 0.05% KIT WITH 1X60GM TUBE PKGCOM |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DESOXIMETASONE 0.05% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESOXIMETASONE 0.05% GEL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESOXIMETASONE 0.25% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESOXIMETASONE 0.25% OINT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DESOXYN 5MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DETROL 1MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DETROL 2MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | 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 |
$45.00 | $112.50 | None |
DETROL LA 4MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXAMETHASONE 1MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEXAMETHASONE 2MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | 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 |
$8.00 | $20.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXAMETHASONE TABLETS |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXASPORIN EYE DROPS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXCHLORPHEN 2MG/5ML SYRUP |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXEDRINE D-AMPHETAMINE SULFATE 10MG CAPSULE SA ORAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXEDRINE D-AMPHETAMINE SULFATE 15MG CAPSULE SA ORAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXEDRINE SPANSULE 5MG 90 EA |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 60 MG |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXRAZOXANE 10 MG/ML INJECTABLE SOLUTION [ZINECARD] |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXRAZOXANE 500MG VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE 10MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE 10%-1/4NS IV TUBEX |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG |
2 |
Tier 2 |
$45.00 | $112.50 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIABETA 1.25MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIABETA TABLETS 2.5MG 100 BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIABETA TABLETS 5MG 1000 BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIAMOX SEQUELS 500MG CAPSULE SA |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIBENZYLINE 10MG CAPSULE |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DICLOFENAC 25MG TABLET EC |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICLOFENAC POTASSIUM 25 MG ORAL CAPSULE [ZIPSOR] |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICLOFENAC SOD 100MG TABLET SA |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOXACILLIN 250MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICYCLOMINE 10MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICYCLOMINE 10MG/ML VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIDANOSINE 200MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIDANOSINE 250MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIDRONEL 400MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFFERIN 0.1% CREAM |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFFERIN 0.1% GEL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFFERIN 0.3% GEL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFFERIN LOTION |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLORASONE 0.05% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIFLORASONE 0.05% OINTMENT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIFLUCAN 100MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLUCAN 150MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLUCAN 200MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLUCAN 200MG/5ML SUSPEN |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLUCAN 50MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLUCAN 50MG/5ML SUSPEN |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLUCAN INJECTION |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIFLUNISAL 500MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIGOXIN 125MCG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIGOXIN 250MCG TABLET (1000 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIGOXIN 50MCG/ML SOLUTION ORAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIHYDROERGOTAMINE 1MG/ML AM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILACOR XR 120MG CAPSULE SA |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILACOR XR 180MG CAPSULE SA |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILACOR XR 240MG CAPSULE SA |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILANTIN 50MG INFATAB |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DILANTIN CAPSULES EXTENDED RELEASE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILANTIN-125 SUS 125/5ML |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILATRATE-SR 40MG CAPSULE |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DILAUDID HP HYDROMORPHONE HCL INJECTION 10MG/ML ML VIALSD |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILAUDID HYDROMORPHONE HCL INJECTION 2MG/ML 10 AMP BOX |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILAUDID HYDROMORPHONE HCL INJECTION 4MG/ML 10 AMP BOX |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILAUDID HYDROMORPHONE HCL ORAL LIQUID 1MG/ML 1 PINT BOTGL |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 2MG 100 TABS BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 4MG 100 TAB BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILAUDID HYDROMORPHONE HCL TABLETS 8MG 100 TAB BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILAUDID HYDROMORPHONE HYDROCHLORIDE INJECTION 1MG/ML 10 AMPULES BOX |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILT-CD 120MG CAPSULE SR 24 HR |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM 30MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM 90MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM ER 420MG CAPSULE SA |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HCL 100MG VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES USP 90MG 1 BLPK |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTIAZEM HYDROCHLORIDE INJECTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DILTZAC ER CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIOVAN 160MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN 320MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN 40MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN 80MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN HCT 160/12.5MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN HCT 160/25MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN HCT 320/12.5MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIOVAN HCT 320/25MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN HCT 80/12.5MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIPHENHYDRAMINE 50MG CAPS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIPHENHYDRAMINE HCL ELIXIR 12.5MG/5ML 20 ML PKG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIPROLENE 0.05% LOTION |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIPROLENE 0.05% OINTMENT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIPROLENE AF 0.05% CREAM |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIPYRIDAMOLE TABETS 25MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIPYRIDAMOLE TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPYRIDAMOLE TABLETS 75MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DITROPAN XL 10 MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DITROPAN XL 15 MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DITROPAN XL 5 MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DIURIL SODIUM 500MG VIAL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIVALPROEX SODIUM 250MG TBEC |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIVALPROEX SODIUM 500MG TBEC |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DIVIGEL 1MG(0.1%) GEL IN PACKET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DOLOPHINE HCL 10MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DOLOPHINE HCL 5MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DORYX 100MG TABLET DR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORYX 75MG TABLET DR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DORYX DELAYED RELEASE TABLETS 150MG |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML; |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOVONEX CREAM |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DOVONEX SOLUTION |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXAZOSIN MESYLATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXAZOSIN MESYLATE TABLET 8MG (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXEPIN 10MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXEPIN 50 MG ORAL CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXEPIN 75MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL] |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DOXIL INJECTION 2MG |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE 100MG VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 75MG CAPSULE DELAYED RELEASE (60 CT) |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DRONABINOL CAPS 10MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DRONABINOL CAPS 2.5MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL CAPS 5MG |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DROXIA 200MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DROXIA 300MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DROXIA 400MG CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DUETACT 30MG-2MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DUETACT 30MG-4MG TABLET |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DULERA INHALATION AEROSOL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DULERA INHALATION AEROSOL |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DUONEB INHALATION SOLUTION 3-.5MG 60 X 3ML CRTN |
3 |
Tier 3 |
$90.00 | $225.00 | P |
DURAGESIC PATCH 100 MCG/HR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DURAGESIC PATCH 12.5 MCG/HR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DURAGESIC PATCH 50 CG/HR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DURAGESIC PATCH 75 MCG/HR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DURAMORPH 0.5MG/ML AMPUL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DURAMORPH 1MG/ML AMPUL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
DUREZOL OPHTHALMIC EMULSION 0.05% 5 ML BOTDR |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DYAZIDE 37.5/25 CAPSULE |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DYNACIN 50MG TABLET |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DYNACIN MINOCYCLINE HCL TABLETS 100MG 50 BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DYNACIN MINOCYCLINE HCL TABLETS 75MG 100 BOT |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DYNACIRC CR TABLETS 10 MG |
3 |
Tier 3 |
$90.00 | $225.00 | None |
DYNACIRC CR TABLETS 5 MG |
3 |
Tier 3 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYRENIUM 100MG CAPSULE |
2 |
Tier 2 |
$45.00 | $112.50 | None |
DYRENIUM 50MG CAPSULE |
2 |
Tier 2 |
$45.00 | $112.50 | None |