2014 Medicare Part D Plan Formulary Information |
Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0)
Benefit Details
|
The Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0) Formulary Drugs Starting with the Letter D in CAMUY County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $310 |
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 |
DACARBAZINE 200MG VIAL |
1 |
Preferred Generic |
25% | 25% | P |
DACOGEN 50MG FOR INJECTION |
3* |
Non-Preferred Brand |
25% | 25% | P |
Daliresp 500ug/1 30 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
DANAZOL 100MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DANAZOL 50MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Preferred Generic |
25% | 25% | None |
DANTROLENE SODIUM 100MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DANTROLENE SODIUM 25MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DANTROLENE SODIUM 50MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DAPSONE TABLETS 100MG 30 BLPK |
1 |
Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE TABLETS 25MG 30 BLPK |
1 |
Preferred Generic |
25% | 25% | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
2 |
Preferred Brand |
25% | 25% | None |
DARAPRIM 25mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
25% | 25% | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
1 |
Preferred Generic |
25% | 25% | P |
DAYTRANA PATCH 1.1 MG/HR |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
DAYTRANA PATCH 1.6 MG/HR |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
DAYTRANA PATCH 2.2 MG/HR |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
DAYTRANA PATCH 3.3 MG/HR |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
Decitabine 50 mg vial [Dacogen] |
1 |
Preferred Generic |
25% | 25% | P |
DEGARELIX 240 MG INJ |
3* |
Non-Preferred Brand |
25% | 25% | P |
DELESTROGEN 40 MG/ML VIAL |
3* |
Non-Preferred Brand |
25% | 25% | P |
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 |
25% | 25% | P |
DELZICOL DR 400 MG CAPSULE |
2 |
Preferred Brand |
25% | 25% | Q:180 /30Days |
DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEMSER CAPSULES 250MG (100 CT) |
2 |
Preferred Brand |
25% | 25% | None |
DENAVIR 1% CREAM |
2 |
Preferred Brand |
25% | 25% | None |
Depacon 100mg/mL 10 VIAL, SINGLE-DOSE in 1 PACKAGE / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Preferred Brand |
25% | 25% | None |
DEPAKENE 250MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Depakene 250mg/5mL 473 mL in 1 BOTTLE |
3* |
Non-Preferred Brand |
25% | 25% | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
1 |
Preferred Generic |
25% | 25% | P |
DEPO-PROVERA 400MG/ML VIAL |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-TESTOSTERONE 100MG/ML |
1 |
Preferred Generic |
25% | 25% | None |
DEPO-TESTOSTERONE 200MG/ML |
1 |
Preferred Generic |
25% | 25% | None |
DESIPRAMINE 10 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DESIPRAMINE 25MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DESIPRAMINE 50MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DESIPRAMINE 75 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
1 |
Preferred Generic |
25% | 25% | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Preferred Generic |
25% | 25% | None |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Preferred Generic |
25% | 25% | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
1 |
Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Preferred Generic |
25% | 25% | None |
DESONIDE 0.05% OINTMENT |
1 |
Preferred Generic |
25% | 25% | None |
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
1 |
Preferred Generic |
25% | 25% | None |
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
desoximetasone 0.05% ointment |
1 |
Preferred Generic |
25% | 25% | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
25% | 25% | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
25% | 25% | None |
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
1 |
Preferred Generic |
25% | 25% | None |
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
25% | 25% | None |
DETROL 1MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
DETROL 2MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DETROL LA 2MG CAPSULE SA |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
DETROL LA 4MG CAPSULE SA |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
DEXAMETHASONE 0.5MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 1.5 MGTABLETS |
3* |
Non-Preferred Brand |
25% | 25% | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
Dexamethasone 10 mg/ml vial |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 1MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 2MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 4MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE 6MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Preferred Generic |
25% | 25% | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Preferred Generic |
25% | 25% | None |
DEXMETHYLPHENIDATE ER 15 MG CP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 30 MG CP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 40 MG CP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
dexrazoxane 500 mg vial |
1 |
Preferred Generic |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 10 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DEXTROAMPHETAMINE 10MG TABLET |
1 |
Preferred Generic |
25% | 25% | Q:180 /30Days |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Preferred Generic |
25% | 25% | Q:150 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | 25% | Q:90 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Preferred Generic |
25% | 25% | Q:120 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
1 |
Preferred Generic |
25% | 25% | Q:180 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Preferred Generic |
25% | 25% | None |
Dextrose And Sodium Chloride 5; 0.9g/100mL; g/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONTAINER |
1 |
Preferred Generic |
25% | 25% | None |
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g 12 CONTAINER in 1 CASE |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Preferred Generic |
25% | 25% | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Preferred Generic |
25% | 25% | 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 |
Preferred Generic |
25% | 25% | None |
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | Q:120 /30Days |
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
Diazepam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:90 /30Days |
Diazepam 5mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:90 /30Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | Q:1200 /30Days |
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER |
1 |
Preferred Generic |
25% | 25% | Q:1200 /30Days |
DICLOFENAC 25MG TABLET EC |
1 |
Preferred Generic |
25% | 25% | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Preferred Generic |
25% | 25% | None |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Preferred Generic |
25% | 25% | None |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Preferred Generic |
25% | 25% | None |
DICYCLOMINE 10MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Preferred Generic |
25% | 25% | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Preferred Generic |
25% | 25% | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Preferred Generic |
25% | 25% | Q:90 /30Days |
DIFLORASONE 0.05% CREAM |
1 |
Preferred Generic |
25% | 25% | None |
DIFLORASONE 0.05% OINTMENT |
1 |
Preferred Generic |
25% | 25% | None |
DIFLUNISAL 500MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER |
1 |
Preferred Generic |
25% | 25% | P |
Digoxin 125ug 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
Digoxin 250ug 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | P |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Preferred Generic |
25% | 25% | P |
DILANTIN 50MG INFATAB |
2 |
Preferred Brand |
25% | 25% | None |
DILANTIN CAPSULES 30 MG EXTENDED RELEASE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
2 |
Preferred Brand |
25% | 25% | None |
DILANTIN-125 SUS 125/5ML |
2 |
Preferred Brand |
25% | 25% | None |
DILT XR 120 MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DILTIAZEM 24HR CD 300 MG CAP |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
diltiazem 25 mg/5 ml vial |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM 30MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM 90MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DILTIAZEM HCL 100MG VIAL |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
diltiazem hcl er 420 mg cap |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
Diltiazem Hydrochloride 90mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
DILTIAZEM HYDROCHLORIDE ER 360MG CAPSULES |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DIOVAN 160MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN 320MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
DIOVAN 40MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
DIOVAN 80MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
DIOVAN HCT 160/12.5MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days |
DIOVAN HCT 160/25MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days |
DIOVAN HCT 320/12.5MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days |
DIOVAN HCT 320/25MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days |
DIOVAN HCT 80/12.5MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
DIPHENOXYLATE/ATROPINE LIQ |
1 |
Preferred Generic |
25% | 25% | None |
DIPHTHERIA-TETANUS TOXOIDS-PED |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Preferred Generic |
25% | 25% | P |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Preferred Generic |
25% | 25% | P |
Disulfiram 250mg/1 |
1 |
Preferred Generic |
25% | 25% | None |
Disulfiram 500mg/1 |
2 |
Preferred Brand |
25% | 25% | None |
DIVALPROEX SODIUM 125 MG CAP |
1 |
Preferred Generic |
25% | 25% | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Preferred Generic |
25% | 25% | None |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Preferred Generic |
25% | 25% | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Preferred Generic |
25% | 25% | None |
DOCEFREZ 1 KIT per CARTON |
3* |
Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOCEFREZ 1 KIT per CARTON |
3* |
Non-Preferred Brand |
25% | 25% | P |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
2 |
Preferred Brand |
25% | 25% | P |
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
2 |
Preferred Brand |
25% | 25% | P |
DOLOPHINE HCL 10MG TABLET |
1 |
Preferred Generic |
25% | 25% | Q:240 /30Days |
DOLOPHINE HYDROCHLORIDE 5mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | Q:480 /30Days |
DONEPEZIL HYDROCHLORIDE 10 MG TABLETS |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DONEPEZIL HYDROCHLORIDE 5 MG TABLETS |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Preferred Generic |
25% | 25% | Q:10 /30Days |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
1 |
Preferred Generic |
25% | 25% | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxazosin 2mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DOXAZOSIN MESYLATE TABLETS 8 MG |
1 |
Preferred Generic |
25% | 25% | None |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Preferred Generic |
25% | 25% | None |
DOXEPIN 10MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | P |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Preferred Generic |
25% | 25% | P |
DOXEPIN 75MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Preferred Generic |
25% | 25% | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
25% | 25% | P |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Preferred Generic |
25% | 25% | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Preferred Generic |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL] |
2 |
Preferred Brand |
25% | 25% | P |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
1 |
Preferred Generic |
25% | 25% | P |
Doxercalciferol 1 mcg capsule [HECTOROL] |
1 |
Preferred Generic |
25% | 25% | P |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
1 |
Preferred Generic |
25% | 25% | P |
Doxercalciferol 4 mcg/2 ml amp [HECTOROL] |
1 |
Preferred Generic |
25% | 25% | P |
DOXIL 2mg/mL |
2 |
Preferred Brand |
25% | 25% | P |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE |
2 |
Preferred Brand |
25% | 25% | P |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | 25% | None |
Doxycycline 75mg/1 |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
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 |
Preferred Generic |
25% | 25% | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST |
1 |
Preferred Generic |
25% | 25% | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | 25% | None |
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
1 |
Preferred Generic |
25% | 25% | None |
DRONABINOL CAPS 10MG |
1 |
Preferred Generic |
25% | 25% | P Q:120 /30Days |
DRONABINOL CAPS 2.5MG |
1 |
Preferred Generic |
25% | 25% | P Q:120 /30Days |
DRONABINOL CAPS 5MG |
1 |
Preferred Generic |
25% | 25% | P Q:120 /30Days |
DROSPIRENONE-ETH ESTRADIOL TAB |
1 |
Preferred Generic |
25% | 25% | None |
DROXIA 200MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DROXIA 300MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
DROXIA 400MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
DULERA INHALATION AEROSOL |
2 |
Preferred Brand |
25% | 25% | Q:13 /30Days |
DULERA INHALATION AEROSOL |
2 |
Preferred Brand |
25% | 25% | Q:13 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
1 |
Preferred Generic |
25% | 25% | Q:60 /30Days |
duramorph 0.5 mg/ml ampule |
3* |
Non-Preferred Brand |
25% | 25% | Q:7200 /30Days |
duramorph 1 mg/ml ampule |
3* |
Non-Preferred Brand |
25% | 25% | Q:3600 /30Days |
DUREZOL 0.05% EYE DROPS |
2 |
Preferred Brand |
25% | 25% | None |
DYMISTA NASAL SPRAY |
2 |
Preferred Brand |
25% | 25% | Q:23 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYRENIUM 100MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
DYRENIUM 50MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |