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Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Tier 1 (1451)
Tier 2 (735)
Tier 3 (314)
Tier 4 (729)
Tier 5 (319)
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2012 Medicare Part D Plan Formulary Information
Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Benefit Details           
The Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 7 which includes: VA
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
D5W/KCL 20MEQ/L IV SOLUTION   2* Non-preferred generic drugs $16.00$48.00None
D5W/KCL 30MEQ/L IV SOLUTION   2* Non-preferred generic drugs $16.00$48.00None
DACARBAZINE 200MG VIAL   2* Non-preferred generic drugs $16.00$48.00P
DACOGEN FOR INJECTION   4 Non-preferred brand name drugs 40%40%P
DANAZOL 100MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00None
DANAZOL 50MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00None
DANAZOL CAPSULES USP 200MG (100 CT)   2* Non-preferred generic drugs $16.00$48.00None
DANTROLENE SODIUM 100MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00None
DANTROLENE SODIUM 25MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00None
DANTROLENE SODIUM 50MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DAPSONE TABLETS 100MG 30 BLPK   1* Preferred generic drugs $3.00$9.00None
DAPSONE TABLETS 25MG 30 BLPK   1* Preferred generic drugs $3.00$9.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   4 Non-preferred brand name drugs 40%40%None
DARAPRIM 25mg/1 100 TABLET in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
daunorubicin hydrochloride 5mg/mL 10 VIAL in 1 CARTON / 4 mL in 1 VIAL   2* Non-preferred generic drugs $16.00$48.00P
DECAVAC VACCINE 2;5 UNT/0.5 ML   4 Non-preferred brand name drugs 40%40%None
DEGARELIX INJ   5 Specialty drugs 25%25%P Q:2
/365Days
DEMECLOCYCLINE HCL 150MG TABLET   2* Non-preferred generic drugs $16.00$48.00P
DEMECLOCYCLINE HCL 300MG TABLET   2* Non-preferred generic drugs $16.00$48.00P
DEMSER CAPSULES 250MG (100 CT)   5 Specialty drugs 25%25%None
DENAVIR 1% CREAM   4 Non-preferred brand name drugs 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEPADE 50MG TABLET   2* Non-preferred generic drugs $16.00$48.00None
DEPEN 250MG TITRATAB   4 Non-preferred brand name drugs 40%40%None
DEPO-ESTRADIOL 5MG/ML VIAL   4 Non-preferred brand name drugs 40%40%None
DEPO-PROVERA 400MG/ML VIAL   4 Non-preferred brand name drugs 40%40%None
DEPO-TESTOSTERONE 100MG/ML   4 Non-preferred brand name drugs 40%40%None
DEPO-TESTOSTERONE 200MG/ML   4 Non-preferred brand name drugs 40%40%None
DERMOTIC 0.01% DROPS   4 Non-preferred brand name drugs 40%40%None
DESIPRAMINE 25MG TABLET   1* Preferred generic drugs $3.00$9.00None
DESIPRAMINE 50MG TABLET   1* Preferred generic drugs $3.00$9.00None
DESIPRAMINE HCL 75MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
DESIPRAMINE HYDROCHLORIDE TABLETS   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
DESMOPRESSIN AC 4MCG/ML VL   2* Non-preferred generic drugs $16.00$48.00None
DESMOPRESSIN ACETATE 0.1MG TABLET   2* Non-preferred generic drugs $16.00$48.00None
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL   2* Non-preferred generic drugs $16.00$48.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   2* Non-preferred generic drugs $16.00$48.00None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)   2* Non-preferred generic drugs $16.00$48.00None
DESONIDE 0.05% CREAM   1* Preferred generic drugs $3.00$9.00None
DESONIDE 0.05% OINTMENT 60GM TUBE   1* Preferred generic drugs $3.00$9.00None
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
DesOwen 0.5mg/g 59 g in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2* Non-preferred generic drugs $16.00$48.00None
Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2* Non-preferred generic drugs $16.00$48.00None
Desoximetasone 2.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2* Non-preferred generic drugs $16.00$48.00None
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE   2* Non-preferred generic drugs $16.00$48.00None
DETROL 1MG TABLET   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
DETROL 2MG TABLET   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
DETROL LA 2MG CAPSULE SA   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
DETROL LA 4MG CAPSULE SA   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
DEXAMETHASONE 0.5MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE 0.5MG/0.5ML DROP   4 Non-preferred brand name drugs 40%40%None
DEXAMETHASONE 0.5MG/5ML ELX   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 0.75MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE 1.5MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE 1MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE 2MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE 4MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE 6MG TABLET   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS   2* Non-preferred generic drugs $16.00$48.00None
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD   1* Preferred generic drugs $3.00$9.00None
DEXAMETHASONE TABLETS   4 Non-preferred brand name drugs 40%40%None
DEXCHLORPHEN 2MG/5ML SYRUP   1* Preferred generic drugs $3.00$9.00P
DEXILANT CAPSULES DELAYED RELEASE 30 MG   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXILANT CAPSULES DELAYED RELEASE 60 MG   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DEXMETHYLPHENIDATE HCL 10MG TABLET   1* Preferred generic drugs $3.00$9.00Q:2
/1Days
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   1* Preferred generic drugs $3.00$9.00Q:2
/1Days
DEXMETHYLPHENIDATE HCL 5MG TABLET   1* Preferred generic drugs $3.00$9.00Q:2
/1Days
DEXRAZOXANE 500MG VIAL   2* Non-preferred generic drugs $16.00$48.00P
DEXTROAMPHETAMINE 10MG TABLET   1* Preferred generic drugs $3.00$9.00Q:6
/1Days
DEXTROAMPHETAMINE 5MG TABLET   1* Preferred generic drugs $3.00$9.00Q:5
/1Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00Q:2
/1Days
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT   2* Non-preferred generic drugs $16.00$48.00Q:4
/1Days
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT   2* Non-preferred generic drugs $16.00$48.00Q:4
/1Days
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT   2* Non-preferred generic drugs $16.00$48.00Q:4
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE 10%-1/4NS IV TUBEX   1* Preferred generic drugs $3.00$9.00None
DEXTROSE 2.5%-1/2NS IV SOLUTION   1* Preferred generic drugs $3.00$9.00None
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG   1* Preferred generic drugs $3.00$9.00None
DEXTROSE 5%-1/4NS IV SOLUTION   1* Preferred generic drugs $3.00$9.00None
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g/100mL; g/100mL; g/100mL; g/100mL; g/100mL 12   1* Preferred generic drugs $3.00$9.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1* Preferred generic drugs $3.00$9.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1* Preferred generic drugs $3.00$9.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   1* Preferred generic drugs $3.00$9.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   1* Preferred generic drugs $3.00$9.00None
DEXTROSE INJECTION 10 250ML X 24 BOTPL   1* Preferred generic drugs $3.00$9.00None
DEXTROSE INJECTION USP 5 4 X 100ML CTR   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC 25MG TABLET EC   1* Preferred generic drugs $3.00$9.00None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)   1* Preferred generic drugs $3.00$9.00None
DICLOFENAC SOD 100MG TABLET SA   1* Preferred generic drugs $3.00$9.00None
DICLOFENAC SODIUM 0.1% DROPS   2* Non-preferred generic drugs $16.00$48.00None
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)   1* Preferred generic drugs $3.00$9.00None
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE   1* Preferred generic drugs $3.00$9.00None
DICLOXACILLIN 250MG CAPSULE   1* Preferred generic drugs $3.00$9.00None
DICLOXACILLIN SODIUM 500MG CAP   1* Preferred generic drugs $3.00$9.00None
DICYCLOMINE 10MG CAPSULE   1* Preferred generic drugs $3.00$9.00P
DICYCLOMINE 10MG/ML VIAL   1* Preferred generic drugs $3.00$9.00P
DICYCLOMINE HCL 10MG/5ML SYRUP   1* Preferred generic drugs $3.00$9.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICYCLOMINE HCL 20MG TABLET (500 CT)   1* Preferred generic drugs $3.00$9.00P
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE   2* Non-preferred generic drugs $16.00$48.00None
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE   2* Non-preferred generic drugs $16.00$48.00None
DIDANOSINE 400MG CAPSULE DELAYED RELEASE   2* Non-preferred generic drugs $16.00$48.00None
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT   2* Non-preferred generic drugs $16.00$48.00None
Dificid 200mg/1 1 BOTTLE in 1 CARTON / 20 TABLET, FILM COATED in 1 BOTTLE   5 Specialty drugs 25%25%P S Q:2
/1Days
DIFLORASONE 0.05% CREAM   1* Preferred generic drugs $3.00$9.00None
DIFLORASONE 0.05% OINTMENT   2* Non-preferred generic drugs $16.00$48.00None
DIFLUNISAL 500MG TABLET   1* Preferred generic drugs $3.00$9.00None
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER   1* Preferred generic drugs $3.00$9.00None
Digoxin 125ug/1 100 TABLET in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Digoxin 250ug/1 100 TABLET in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
DIGOXIN INJECTION 500MCG 25 X 2ML AMP   1* Preferred generic drugs $3.00$9.00None
Dihydroergotamine Mesylate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL   2* Non-preferred generic drugs $16.00$48.00None
DILACOR XR 240MG CAPSULE SA   4 Non-preferred brand name drugs 40%40%None
DILANTIN 50MG INFATAB   4 Non-preferred brand name drugs 40%40%None
DILANTIN CAPSULES EXTENDED RELEASE   4 Non-preferred brand name drugs 40%40%None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   4 Non-preferred brand name drugs 40%40%None
DILT-CD 120MG CAPSULE SR 24 HR   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG   1* Preferred generic drugs $3.00$9.00None
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE   1* Preferred generic drugs $3.00$9.00Q:3
/1Days
DILTIAZEM 30MG TABLET   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 90MG TABLET   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM CD CAPSULES 120MG (90 CT)   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
DILTIAZEM CD CAPSULES 240MG (90 CT)   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM CD CAPSULES 300MG (90 CT)   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM ER 240MG CAPSULE SA   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM ER 420MG CAPSULE SA   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM HCL 100MG VIAL   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM HCL 120MG ER CAPSULE   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM HCL 120MG TABLET   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM HCL 60MG ER CAPSULE   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM HCL 60MG TABLET   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Diltiazem Hydrochloride 90mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM HYDROCHLORIDE CAPSULES EXTENDED RELEASE   1* Preferred generic drugs $3.00$9.00None
DILTIAZEM INJ 25MG/5ML   1* Preferred generic drugs $3.00$9.00None
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG   1* Preferred generic drugs $3.00$9.00Q:3
/1Days
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG   1* Preferred generic drugs $3.00$9.00None
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG   1* Preferred generic drugs $3.00$9.00None
DIOVAN 160MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
DIOVAN 320MG TABLET   3 Preferred brand name drugs $35.00$105.00None
DIOVAN 40MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
DIOVAN 80MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIOVAN HCT 160/12.5MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DIOVAN HCT 160/25MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DIOVAN HCT 320/12.5MG TABLET   3 Preferred brand name drugs $35.00$105.00None
DIOVAN HCT 320/25MG TABLET   3 Preferred brand name drugs $35.00$105.00None
DIOVAN HCT 80/12.5MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DIPHENHYDRAMINE 50MG CAPS   1* Preferred generic drugs $3.00$9.00P
DIPHENHYDRAMINE HCL ELIXIR 12.5MG/5ML 20 ML PKG   1* Preferred generic drugs $3.00$9.00P
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL   1* Preferred generic drugs $3.00$9.00P
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg/1; mg/1 100 TABLET in 1 BOTTLE, PLAST   1* Preferred generic drugs $3.00$9.00P
DIPHENOXYLATE/ATROPINE LIQ   1* Preferred generic drugs $3.00$9.00P
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF   2* Non-preferred generic drugs $16.00$48.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Dipyridamole 25mg/1 100 TABLET in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
Dipyridamole 75mg/1 100 TABLET in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
DIPYRIDAMOLE TABLETS 50MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)   1* Preferred generic drugs $3.00$9.00None
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)   1* Preferred generic drugs $3.00$9.00None
Disulfiram 250mg/1   2* Non-preferred generic drugs $16.00$48.00None
Disulfiram 500mg/1   2* Non-preferred generic drugs $16.00$48.00None
DIVALPROEX SODIUM 125MG TBEC   1* Preferred generic drugs $3.00$9.00None
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
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* Preferred generic drugs $3.00$9.00None
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
DOCEFREZ 1 KIT in 1 CARTON   5 Specialty drugs 25%25%P
DOCEFREZ 1 KIT in 1 CARTON   5 Specialty drugs 25%25%P
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 8 mL in 1 VIAL, MULTI-DOSE   2* Non-preferred generic drugs $16.00$48.00P
Docetaxel 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS   2* Non-preferred generic drugs $16.00$48.00P
donepezil hydrochloride 10mg/1   2* Non-preferred generic drugs $16.00$48.00Q:2
/1Days
donepezil hydrochloride 5mg/1   2* Non-preferred generic drugs $16.00$48.00Q:1
/1Days
DONEPEZIL HYDROCHLORIDE TABLETS   2* Non-preferred generic drugs $16.00$48.00Q:2
/1Days
DONEPEZIL HYDROCHLORIDE TABLETS   2* Non-preferred generic drugs $16.00$48.00Q:1
/1Days
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Dorzolamide HCL Timolol Maleate Ophthalmic Solution 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER i   2* Non-preferred generic drugs $16.00$48.00None
Doxazosin 2mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
DOXAZOSIN MESYLATE 4MG TABLET   1* Preferred generic drugs $3.00$9.00None
DOXAZOSIN MESYLATE TABLETS 8 MG   1* Preferred generic drugs $3.00$9.00None
DOXAZOSIN TABLET 1MG (100 CT)   1* Preferred generic drugs $3.00$9.00None
DOXEPIN 10MG CAPSULE   1* Preferred generic drugs $3.00$9.00None
DOXEPIN 10MG/ML ORAL CONC   1* Preferred generic drugs $3.00$9.00None
DOXEPIN 75MG CAPSULE   1* Preferred generic drugs $3.00$9.00None
DOXEPIN HCL 25MG CAPSULE (100 CT)   1* Preferred generic drugs $3.00$9.00None
Doxepin Hydrochloride 150mg/1 100 CAPSULE in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD   2* Non-preferred generic drugs $16.00$48.00P
DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD   2* Non-preferred generic drugs $16.00$48.00P
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE   2* Non-preferred generic drugs $16.00$48.00P
DOXYCYCLINE 50MG CAPSULE   1* Preferred generic drugs $3.00$9.00P
DOXYCYCLINE 50MG TABLET (100 CT)   2* Non-preferred generic drugs $16.00$48.00P
Doxycycline 75mg/1   2* Non-preferred generic drugs $16.00$48.00P
DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN   2* Non-preferred generic drugs $16.00$48.00P
DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE   1* Preferred generic drugs $3.00$9.00P
Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC   2* Non-preferred generic drugs $16.00$48.00P
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE in 1 BOTTLE, PLAST   1* Preferred generic drugs $3.00$9.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00P
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC   2* Non-preferred generic drugs $16.00$48.00P
DOXYCYCLINE HYCLATE CAPSULES DELAYED RELEASE 75 MG   1* Preferred generic drugs $3.00$9.00P
DOXYCYCLINE HYCLATE TAB 150MG   2* Non-preferred generic drugs $16.00$48.00P
DOXYCYCLINE MONOHYDRATE 75MG TABLET   2* Non-preferred generic drugs $16.00$48.00P
DOXYCYCLINE TABLETS 150MG 30 BOT   2* Non-preferred generic drugs $16.00$48.00P
DRONABINOL CAPS 10MG   2* Non-preferred generic drugs $16.00$48.00P Q:2
/1Days
DRONABINOL CAPS 2.5MG   2* Non-preferred generic drugs $16.00$48.00P Q:2
/1Days
DRONABINOL CAPS 5MG   2* Non-preferred generic drugs $16.00$48.00P Q:2
/1Days
DROXIA 200MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
DROXIA 300MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DROXIA 400MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
DUETACT 30MG-2MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DUETACT 30MG-4MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DULERA INHALATION AEROSOL   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DULERA INHALATION AEROSOL   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
DURAMORPH 0.5MG/ML AMPUL   1* Preferred generic drugs $3.00$9.00None
DURAMORPH 1MG/ML AMPUL   1* Preferred generic drugs $3.00$9.00None
DUREZOL 0.5mg/mL 5 mL in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00None
DYNACIN 100mg/1 50 TABLET in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%P
DYNACIN 50mg/1 100 TABLET in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%P
DYNACIN 75mg/1 100 TABLET in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%P

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Aetna CVS/pharmacy Prescription Drug Plan (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $320 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2012 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.





 
 

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.