| 2012 Medicare Part D Plan Formulary Information |
|---|
PrimeTime Prescription Drug Plan Basic (PDP) (S1480-001-0)
Benefit Details
 |
The PrimeTime Prescription Drug Plan Basic (PDP) (S1480-001-0)
Formulary Drugs Starting with the Letter D
in CMS PDP Region 14 which includes: OH
|
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  |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | Q:24
/30Days |
| D5W/KCL 20MEQ/L IV SOLUTION |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| D5W/KCL 30MEQ/L IV SOLUTION |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DACARBAZINE 200MG VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DACOGEN FOR INJECTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Daliresp 500ug/1 30 TABLET in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DANAZOL 100MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DANAZOL 50MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Dantrium 100mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DANTRIUM 25 MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DANTRIUM 50 MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DANTROLENE SODIUM 100MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DANTROLENE SODIUM 25MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DANTROLENE SODIUM 50MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DAPSONE TABLETS 100MG 30 BLPK |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DAPSONE TABLETS 25MG 30 BLPK |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DARAPRIM 25mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| daunorubicin hydrochloride 5mg/mL 10 VIAL in 1 CARTON / 4 mL in 1 VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DAUNOXOME INJECTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DAYPRO 600MG CAPLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DAYTRANA PATCH 1.1 MG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DAYTRANA PATCH 1.6 MG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DAYTRANA PATCH 2.2 MG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DAYTRANA PATCH 3.3 MG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DDAVP 0.01% NASAL SPRAY |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DDAVP 0.1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DDAVP 0.2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DDAVP 4MCG/ML AMPUL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DDAVP SOLUTION INTRANASAL 0.1MG/ML 2.5 ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DECAVAC VACCINE 2;5 UNT/0.5 ML |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEGARELIX INJ |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DELATESTRYL 200 MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DELESTROGEN 40 MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DELESTROGEN INJECTION 10MG/5ML VIALMD |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DELESTROGEN INJECTION 20MG/5ML VIALMD |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEMADEX TABLETS 10MG 10 GM BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEMADEX TABLETS 20MG 20 MG BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEMADEX TBALETS 5MG 5 MG BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEMEROL 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEMEROL 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEMEROL 50MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEMSER CAPSULES 250MG (100 CT) |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DENAVIR 1% CREAM |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| Depacon 100mg/mL 10 VIAL, SINGLE-DOSE in 1 PACKAGE / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DEPADE 50MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEPAKENE 250MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Depakene 250mg/5mL 473 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DEPAKOTE 125MG SPRINKLE CAP |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPAKOTE 125MG TABLET EC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPAKOTE 250MG TABLET EC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEPAKOTE 500MG TABLET EC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPAKOTE ER 250MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPAKOTE ER 500MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPEN 250MG TITRATAB |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-ESTRADIOL 5MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-MEDROL 20MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-MEDROL 40MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-MEDROL 80MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-PROVERA 400MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-TESTOSTERONE 100MG/ML |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEPO-TESTOSTERONE 200MG/ML |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DERMA-SMOOTHE/FS 0.01% BODY OIL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DERMATOP 0.1% CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DERMATOP 0.1% OINTMENT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DERMOTIC 0.01% DROPS |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DESIPRAMINE 25MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESIPRAMINE 50MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESIPRAMINE HCL 75MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESIPRAMINE HYDROCHLORIDE TABLETS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESMOPRESSIN AC 4MCG/ML VL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESOGEN 28 DAY TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DESONATE GEL 0.05% |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DESONIDE 0.05% CREAM |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESONIDE 0.05% OINTMENT 60GM TUBE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DesOwen 0.5mg/g 59 g in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DesOwen 0.5mg/g 60 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DESOWEN OINTMENT 0.05% KIT WITH 1X60GM TUBE PKGCOM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Desoximetasone 2.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DESOXYN 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DETROL 1MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DETROL 2MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DETROL LA 2MG CAPSULE SA |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DETROL LA 4MG CAPSULE SA |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DEXAMETHASONE 0.5MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEXAMETHASONE 0.5MG/0.5ML DROP |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE 0.75MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE 1.5MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE 1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXAMETHASONE 2MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE 4MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE 6MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXAMETHASONE TABLETS |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEXCHLORPHEN 2MG/5ML SYRUP |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXEDRINE 10mg/1 90 BOTTLE, PLASTIC in 1 CARTON / 90 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXEDRINE 15mg/1 90 BOTTLE in 1 CARTON / 90 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXEDRINE 5mg/1 90 BOTTLE, PLASTIC in 1 CARTON / 90 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXILANT CAPSULES DELAYED RELEASE 30 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXILANT CAPSULES DELAYED RELEASE 60 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXRAZOXANE 500MG VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROAMPHETAMINE 10MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEXTROAMPHETAMINE 5MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | 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 |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE IN SODIUM CHLORIDE INJECTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DIABETA 1.25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DiaBeta 5mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIABETA TABLETS 2.5MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIAMOX SEQUELS 500MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIBENZYLINE 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DICLOFENAC 25MG TABLET EC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOFENAC POTASSIUM 25 MG ORAL CAPSULE [ZIPSOR] |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOFENAC SOD 100MG TABLET SA |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOFENAC SODIUM 0.1% DROPS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOXACILLIN 250MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICLOXACILLIN SODIUM 500MG CAP |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DICYCLOMINE 10MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DICYCLOMINE 10MG/ML VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIDRONEL 400MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFFERIN 0.1% CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFFERIN 0.1% GEL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFFERIN 3mg/g 45 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFFERIN LOTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Dificid 200mg/1 1 BOTTLE in 1 CARTON / 20 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLORASONE 0.05% CREAM |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIFLORASONE 0.05% OINTMENT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIFLUCAN 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUCAN 150MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUCAN 200MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUCAN 200MG/5ML SUSPEN |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUCAN 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUCAN 50MG/5ML SUSPEN |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUCAN INJECTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIFLUNISAL 500MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Digoxin 125ug/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Digoxin 250ug/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Dihydroergotamine Mesylate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | Q:24
/30Days |
| DILACOR XR 240MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILANTIN 50MG INFATAB |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DILANTIN CAPSULES EXTENDED RELEASE |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILANTIN-125 SUS 125/5ML |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILATRATE-SR 40 MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DILAUDID HP HYDROMORPHONE HCL INJECTION 10MG/ML ML VIALSD |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HCL INJECTION 2MG/ML 10 AMP BOX |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HCL INJECTION 4MG/ML 10 AMP BOX |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HCL ORAL LIQUID 1MG/ML 1 PINT BOTGL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HCL TABLETS 2MG 100 TABS BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HCL TABLETS 4MG 100 TAB BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HCL TABLETS 8MG 100 TAB BOT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILAUDID HYDROMORPHONE HYDROCHLORIDE INJECTION 1MG/ML 10 AMPULES BOX |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILT-CD 120MG CAPSULE SR 24 HR |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DILTIAZEM 30MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM 90MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM CD CAPSULES 300MG (90 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM ER 240MG CAPSULE SA |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM ER 420MG CAPSULE SA |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM HCL 100MG VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM HCL 120MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DILTIAZEM HCL 60MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Diltiazem Hydrochloride 90mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTIAZEM INJ 25MG/5ML |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIOVAN 160MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN 320MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DIOVAN 40MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN 80MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN HCT 160/12.5MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN HCT 160/25MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN HCT 320/12.5MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN HCT 320/25MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIOVAN HCT 80/12.5MG TABLET |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | None |
| DIPHENHYDRAMINE HCL ELIXIR 12.5MG/5ML 20 ML PKG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg/1; mg/1 100 TABLET in 1 BOTTLE, PLAST |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DIPHENOXYLATE/ATROPINE LIQ |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIPROLENE 0.05% LOTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIPROLENE 0.05% OINTMENT |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIPROLENE AF 0.05% CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Dipyridamole 25mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Dipyridamole 75mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIPYRIDAMOLE TABLETS 50MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Disulfiram 250mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Disulfiram 500mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DITROPAN XL 10 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DITROPAN XL 15 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DITROPAN XL 5 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIURIL 250MG/5ML SUSPENSION ORAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIURIL SODIUM 500MG VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DIVALPROEX SODIUM 125MG TBEC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Divigel 1.0mg/g 30 PACKET in 1 CARTON / 1.0 g in 1 PACKET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DOCEFREZ 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DOCEFREZ 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Docetaxel 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DOLOPHINE HCL 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DOLOPHINE HYDROCHLORIDE 5mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| donepezil hydrochloride 10mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| donepezil hydrochloride 5mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DONEPEZIL HYDROCHLORIDE TABLETS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DORIBAX FOR INJECTION 500MG/VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DORYX 75MG TABLET DR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DORYX DR 150 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Dorzolamide HCL Timolol Maleate Ophthalmic Solution 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER i |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOVONEX CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DOVONEX SOLUTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Doxazosin 2mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXAZOSIN MESYLATE TABLETS 8 MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DOXEPIN 10MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXEPIN 10MG/ML ORAL CONC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXEPIN 75MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Doxepin Hydrochloride 150mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL] |
2 |
Preferred Brand Drugs |
$29.00 | $87.00 | P |
| DOXIL 2mg/mL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXORUBICIN HCL SOLUTION INJECTION USP 2MG 100ML VIALMD |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE 50MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Doxycycline 75mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE in 1 BOTTLE, PLAST |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE HYCLATE CAPSULES DELAYED RELEASE 75 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DOXYCYCLINE HYCLATE TAB 150MG |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DOXYCYCLINE TABLETS 150MG 30 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DRONABINOL CAPS 10MG |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DRONABINOL CAPS 2.5MG |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DRONABINOL CAPS 5MG |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
| DROXIA 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DROXIA 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DROXIA 400MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DUETACT 30MG-2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DUETACT 30MG-4MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DUEXIS 26.6; 800mg/1; mg/1 |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DULERA INHALATION AEROSOL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DULERA INHALATION AEROSOL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DUONEB INHALATION SOLUTION 3-.5MG 60 X 3ML CRTN |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | P |
| DURAGESIC 25ug/h 5 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 72 h in 1 PATCH |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DURAGESIC PATCH 100 MCG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DURAGESIC PATCH 12.5 MCG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DURAGESIC PATCH 50 CG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DURAGESIC PATCH 75 MCG/HR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DURAMORPH 0.5MG/ML AMPUL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| DURAMORPH 1MG/ML AMPUL |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| DUREZOL 0.5mg/mL 5 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYAZIDE 37.5/25 CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYMISTA 137/ 50MCG SPY 23 GM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYNACIN 100mg/1 50 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYNACIN 50mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYNACIN 75mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYNACIRC CR TABLETS 10 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYNACIRC CR TABLETS 5 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYRENIUM 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |
| DYRENIUM 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $195.00 | None |