2012 Medicare Part D Plan Formulary Information |
RxBLUE PLUS (PDP) (S5937-002-0)
Benefit Details
|
The RxBLUE PLUS (PDP) (S5937-002-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 21 which includes: LA
|
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 |
Specialty Tier Drugs |
33% | 33% | None |
D5W/KCL 20MEQ/L IV SOLUTION |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
D5W/KCL 30MEQ/L IV SOLUTION |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DACOGEN FOR INJECTION |
4 |
Specialty Tier Drugs |
33% | 33% | None |
Daliresp 500ug/1 30 TABLET in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DANAZOL 100MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DANAZOL 50MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Dantrium 100mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DANTRIUM 25 MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTRIUM 50 MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DAPSONE TABLETS 25MG 30 BLPK |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DARAPRIM 25mg/1 100 TABLET in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DAYPRO 600MG CAPLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DAYTRANA PATCH 1.1 MG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DAYTRANA PATCH 1.6 MG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAYTRANA PATCH 2.2 MG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DAYTRANA PATCH 3.3 MG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DDAVP 0.01% NASAL SPRAY |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DDAVP 0.1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DDAVP 0.2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DDAVP 4MCG/ML AMPUL |
4 |
Specialty Tier Drugs |
33% | 33% | None |
DDAVP SOLUTION INTRANASAL 0.1MG/ML 2.5 ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DECAVAC VACCINE 2;5 UNT/0.5 ML |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DELATESTRYL 200 MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DELESTROGEN 40 MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DELESTROGEN INJECTION 20MG/5ML VIALMD |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEMADEX TABLETS 10MG 10 GM BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEMADEX TABLETS 20MG 20 MG BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEMADEX TBALETS 5MG 5 MG BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEMEROL 50MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DENAVIR 1% CREAM |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
Depacon 100mg/mL 10 VIAL, SINGLE-DOSE in 1 PACKAGE / 5 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEPADE 50MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPAKENE 250MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
Depakene 250mg/5mL 473 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPAKOTE 125MG SPRINKLE CAP |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPAKOTE 125MG TABLET EC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPAKOTE 250MG TABLET EC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPAKOTE 500MG TABLET EC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPAKOTE ER 250MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPAKOTE ER 500MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEPEN 250MG TITRATAB |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEPO-MEDROL 20MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-MEDROL 40MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEPO-MEDROL 80MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEPO-PROVERA 150MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | Q:1 /90Days |
DEPO-PROVERA 400MG/ML VIAL |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | Q:1 /90Days |
DEPO-TESTOSTERONE 100MG/ML |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEPO-TESTOSTERONE 200MG/ML |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DERMA-SMOOTHE/FS 0.01% BODY OIL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DERMATOP 0.1% CREAM |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DERMATOP 0.1% OINTMENT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DERMOTIC 0.01% DROPS |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 25MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESIPRAMINE 50MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESIPRAMINE HCL 75MG TABLET (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOGEN 28 DAY TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DESONATE GEL 0.05% |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DESONIDE 0.05% CREAM |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESONIDE 0.05% OINTMENT 60GM TUBE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DesOwen 0.5mg/g 59 g in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DesOwen 0.5mg/g 60 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DESOWEN OINTMENT 0.05% KIT WITH 1X60GM TUBE PKGCOM |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Desoximetasone 2.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DESOXYN 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DETROL 1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DETROL 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DETROL LA 2MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DETROL LA 4MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEXAMETHASONE 0.5MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 1MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 2MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXAMETHASONE TABLETS |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEXCHLORPHEN 2MG/5ML SYRUP |
1 |
Generic Drugs |
$3.00 | $9.00 | P |
DEXEDRINE 10mg/1 90 BOTTLE, PLASTIC in 1 CARTON / 90 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEXEDRINE 15mg/1 90 BOTTLE in 1 CARTON / 90 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DEXEDRINE 5mg/1 90 BOTTLE, PLASTIC in 1 CARTON / 90 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S Q:34 /34Days |
DEXILANT CAPSULES DELAYED RELEASE 60 MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROAMPHETAMINE 10MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g/100mL; g/100mL; g/100mL; g/100mL; g/100mL 12 |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIABETA 1.25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DiaBeta 5mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIABETA TABLETS 2.5MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIAMOX SEQUELS 500MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIBENZYLINE 10MG CAPSULE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DICLOFENAC 25MG TABLET EC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DICLOFENAC POTASSIUM 25 MG ORAL CAPSULE [ZIPSOR] |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DICLOFENAC SOD 100MG TABLET SA |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIDRONEL 400MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIFFERIN 0.1% CREAM |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
DIFFERIN 0.1% GEL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFFERIN 3mg/g 45 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
DIFFERIN LOTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
Dificid 200mg/1 1 BOTTLE in 1 CARTON / 20 TABLET, FILM COATED in 1 BOTTLE |
4 |
Specialty Tier Drugs |
33% | 33% | None |
DIFLORASONE 0.05% CREAM |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIFLORASONE 0.05% OINTMENT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIFLUCAN 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
DIFLUCAN 150MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | Q:2 /7Days |
DIFLUCAN 200MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
DIFLUCAN 200MG/5ML SUSPEN |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIFLUCAN 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
DIFLUCAN 50MG/5ML SUSPEN |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLUCAN INJECTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIFLUNISAL 500MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Digoxin 125ug/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Digoxin 250ug/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Dihydroergotamine Mesylate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILACOR XR 240MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILANTIN 50MG INFATAB |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DILANTIN CAPSULES EXTENDED RELEASE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILANTIN-125 SUS 125/5ML |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILATRATE-SR 40 MG CAPSULE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DILAUDID HP HYDROMORPHONE HCL INJECTION 10MG/ML ML VIALSD |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HCL INJECTION 2MG/ML 10 AMP BOX |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HCL INJECTION 4MG/ML 10 AMP BOX |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HCL ORAL LIQUID 1MG/ML 1 PINT BOTGL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 2MG 100 TABS BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 4MG 100 TAB BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HCL TABLETS 8MG 100 TAB BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILAUDID HYDROMORPHONE HYDROCHLORIDE INJECTION 1MG/ML 10 AMPULES BOX |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DILT-CD 120MG CAPSULE SR 24 HR |
1 |
Generic Drugs |
$3.00 | $9.00 | 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 |
Generic Drugs |
$3.00 | $9.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM 30MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM 90MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM CD CAPSULES 300MG (90 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM ER 420MG CAPSULE SA |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM HCL 100MG VIAL |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 120MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Diltiazem Hydrochloride 90mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTIAZEM INJ 25MG/5ML |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN 160MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN 320MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN 40MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN 80MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN HCT 160/12.5MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN HCT 160/25MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN HCT 320/12.5MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN HCT 320/25MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIOVAN HCT 80/12.5MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S |
DIPHENHYDRAMINE 50MG CAPS |
1 |
Generic Drugs |
$3.00 | $9.00 | P |
DIPHENHYDRAMINE HCL ELIXIR 12.5MG/5ML 20 ML PKG |
1 |
Generic Drugs |
$3.00 | $9.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg/1; mg/1 100 TABLET in 1 BOTTLE, PLAST |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DIPROLENE 0.05% LOTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DIPROLENE 0.05% OINTMENT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DIPROLENE AF 0.05% CREAM |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
Dipyridamole 25mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Dipyridamole 75mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIPYRIDAMOLE TABLETS 50MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Disulfiram 250mg/1 |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Disulfiram 500mg/1 |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DITROPAN XL 10 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DITROPAN XL 15 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DITROPAN XL 5 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S Q:34 /34Days |
DIURIL 250MG/5ML SUSPENSION ORAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DIURIL SODIUM 500MG VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Divigel 1.0mg/g 30 PACKET in 1 CARTON / 1.0 g in 1 PACKET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | Q:34 /34Days |
DOLOPHINE HCL 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DOLOPHINE HYDROCHLORIDE 5mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
donepezil hydrochloride 10mg/1 |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
donepezil hydrochloride 5mg/1 |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DORIBAX FOR INJECTION 500MG/VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | None |
DORYX 75MG TABLET DR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DORYX DR 150 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Dorzolamide HCL Timolol Maleate Ophthalmic Solution 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER i |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOVONEX CREAM |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DOVONEX SOLUTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Doxazosin 2mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | Q:34 /34Days |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | Q:34 /34Days |
DOXAZOSIN MESYLATE TABLETS 8 MG |
1 |
Generic Drugs |
$3.00 | $9.00 | Q:68 /34Days |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | Q:34 /34Days |
DOXEPIN 10MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXEPIN 75MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Doxepin Hydrochloride 150mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL] |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Doxycycline 75mg/1 |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE in 1 BOTTLE, PLAST |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE HYCLATE CAPSULES DELAYED RELEASE 75 MG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE HYCLATE TAB 150MG |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
1 |
Generic Drugs |
$3.00 | $9.00 | None |
DRONABINOL CAPS 10MG |
4 |
Specialty Tier Drugs |
33% | 33% | P |
DRONABINOL CAPS 2.5MG |
1 |
Generic Drugs |
$3.00 | $9.00 | P |
DRONABINOL CAPS 5MG |
1 |
Generic Drugs |
$3.00 | $9.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DROXIA 200MG CAPSULE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DROXIA 300MG CAPSULE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DROXIA 400MG CAPSULE |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | None |
DUETACT 30MG-2MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S Q:34 /34Days |
DUETACT 30MG-4MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | $105.00 | S Q:34 /34Days |
DUEXIS 26.6; 800mg/1; mg/1 |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DULERA INHALATION AEROSOL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P Q:26 /34Days |
DULERA INHALATION AEROSOL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | P Q:26 /34Days |
DURAGESIC 25ug/h 5 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 72 h in 1 PATCH |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DURAGESIC PATCH 100 MCG/HR |
4 |
Specialty Tier Drugs |
33% | 33% | None |
DURAGESIC PATCH 12.5 MCG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DURAGESIC PATCH 50 CG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DURAGESIC PATCH 75 MCG/HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DURAMORPH 0.5MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DURAMORPH 1MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DUREZOL 0.5mg/mL 5 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DYAZIDE 37.5/25 CAPSULE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DYMISTA 137/ 50MCG SPY 23 GM |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S Q:46 /34Days |
DYNACIN 100mg/1 50 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DYNACIN 50mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DYNACIN 75mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DYNACIRC CR TABLETS 10 MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYNACIRC CR TABLETS 5 MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | S |
DYRENIUM 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |
DYRENIUM 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $210.00 | None |