2014 Medicare Part D Plan Formulary Information |
MCS Classicare Platino M (H5577-009-0)
Benefit Details
|
The MCS Classicare Platino M (H5577-009-0) Formulary Drugs Starting with the Letter D in SAN SEBASTIAN 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 |
Tier 1 |
15% | 15% | None |
Daliresp 500ug/1 30 TABLET BOTTLE, PLASTIC |
3 |
Tier 3 |
15% | 15% | P |
DANAZOL 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DANAZOL 50MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
DANTROLENE SODIUM 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DANTROLENE SODIUM 25MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DANTROLENE SODIUM 50MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DAPSONE TABLETS 100MG 30 BLPK |
1 |
Tier 1 |
15% | 15% | None |
DAPSONE TABLETS 25MG 30 BLPK |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
2 |
Tier 2 |
15% | 15% | None |
DARAPRIM 25mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
1 |
Tier 1 |
15% | 15% | None |
Decitabine 50 mg vial [Dacogen] |
4 |
Tier 4 |
15% | 15% | P |
DELZICOL DR 400 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:360 /30Days |
DEMECLOCYCLINE HCL 150MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEMECLOCYCLINE HCL 300MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DESIPRAMINE 10 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DESIPRAMINE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DESIPRAMINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DESIPRAMINE 75 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
1 |
Tier 1 |
15% | 15% | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
desloratadine 2.5 mg odt |
1 |
Tier 1 |
15% | 15% | None |
desloratadine 5 mg odt |
1 |
Tier 1 |
15% | 15% | None |
DESLORATADINE 5 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Tier 1 |
15% | 15% | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
1 |
Tier 1 |
15% | 15% | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
DESONIDE 0.05% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
desoximetasone 0.05% ointment |
1 |
Tier 1 |
15% | 15% | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
DESVENLAFAXINE ER 100 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
DESVENLAFAXINE ER 50 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DEXAMETHASONE 0.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Dexamethasone 10 mg/ml vial |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 1MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 2MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 4MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE 6MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Tier 1 |
15% | 15% | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Tier 1 |
15% | 15% | None |
DEXMETHYLPHENIDATE ER 15 MG CP |
1 |
Tier 1 |
15% | 15% | None |
DEXMETHYLPHENIDATE ER 30 MG CP |
1 |
Tier 1 |
15% | 15% | None |
DEXMETHYLPHENIDATE ER 40 MG CP |
1 |
Tier 1 |
15% | 15% | None |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
Dextrose And Sodium Chloride 5; 0.9g/100mL; g/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONTAINER |
1 |
Tier 1 |
15% | 15% | None |
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g 12 CONTAINER in 1 CASE |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Tier 1 |
15% | 15% | None |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Tier 1 |
15% | 15% | None |
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:5 /28Days |
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:5 /28Days |
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:5 /28Days |
Diazepam 2mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Diazepam 5mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:1200 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER |
1 |
Tier 1 |
15% | 15% | Q:240 /30Days |
DICLOFENAC 25MG TABLET EC |
1 |
Tier 1 |
15% | 15% | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Tier 1 |
15% | 15% | Q:5 /25Days |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
diclofenac-misoprost 50-0.2 tablet |
1 |
Tier 1 |
15% | 15% | None |
diclofenac-misoprost 75-0.2 tablet |
1 |
Tier 1 |
15% | 15% | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Tier 1 |
15% | 15% | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 |
15% | 15% | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Tier 1 |
15% | 15% | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
4 |
Tier 4 |
15% | 15% | S Q:20 /10Days |
DIFLORASONE 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
DIFLORASONE 0.05% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
DIFLUNISAL 500MG TABLET |
1 |
Tier 1 |
15% | 15% | 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 |
Tier 1 |
15% | 15% | None |
Digoxin 125ug 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Digoxin 250ug 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | P |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Tier 1 |
15% | 15% | None |
DILANTIN 50MG INFATAB |
2 |
Tier 2 |
15% | 15% | None |
DILANTIN CAPSULES 30 MG EXTENDED RELEASE |
2 |
Tier 2 |
15% | 15% | None |
DILT XR 120 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Tier 1 |
15% | 15% | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 24HR CD 300 MG CAP |
1 |
Tier 1 |
15% | 15% | None |
diltiazem 25 mg/5 ml vial |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 30MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 90MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
diltiazem hcl er 420 mg cap |
1 |
Tier 1 |
15% | 15% | None |
Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diltiazem Hydrochloride 90mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM HYDROCHLORIDE ER 360MG CAPSULES |
1 |
Tier 1 |
15% | 15% | None |
DIOVAN 160MG TABLET |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days |
DIOVAN 320MG TABLET |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days |
DIOVAN 40MG TABLET |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days |
DIOVAN 80MG TABLET |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days |
diphenhydramine 50 mg/ml vial |
1 |
Tier 1 |
15% | 15% | None |
Disulfiram 250mg/1 |
1 |
Tier 1 |
15% | 15% | None |
Disulfiram 500mg/1 |
1 |
Tier 1 |
15% | 15% | None |
DIVALPROEX SODIUM 125 MG CAP |
1 |
Tier 1 |
15% | 15% | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
DOCEFREZ 1 KIT per CARTON |
4 |
Tier 4 |
15% | 15% | None |
DOCEFREZ 1 KIT per CARTON |
4 |
Tier 4 |
15% | 15% | None |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
4 |
Tier 4 |
15% | 15% | None |
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Tier 4 |
15% | 15% | None |
DONEPEZIL HCL 23 MG TABLET |
1 |
Tier 1 |
15% | 15% | P Q:31 /31Days |
DONEPEZIL HYDROCHLORIDE 10 MG TABLETS |
1 |
Tier 1 |
15% | 15% | P Q:31 /31Days |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Tier 1 |
15% | 15% | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DONEPEZIL HYDROCHLORIDE 5 MG TABLETS |
1 |
Tier 1 |
15% | 15% | P Q:31 /31Days |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Tier 1 |
15% | 15% | P Q:31 /31Days |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Tier 1 |
15% | 15% | Q:10 /25Days |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
1 |
Tier 1 |
15% | 15% | Q:10 /25Days |
Doxazosin 2mg 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DOXAZOSIN MESYLATE TABLETS 8 MG |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DOXEPIN 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | S |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Tier 1 |
15% | 15% | S |
DOXEPIN 75MG CAPSULE |
1 |
Tier 1 |
15% | 15% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
15% | 15% | S |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | S |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Tier 1 |
15% | 15% | S |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Tier 1 |
15% | 15% | S |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
1 |
Tier 1 |
15% | 15% | None |
Doxercalciferol 1 mcg capsule [HECTOROL] |
1 |
Tier 1 |
15% | 15% | None |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
1 |
Tier 1 |
15% | 15% | None |
Doxercalciferol 4 mcg/2 ml amp [HECTOROL] |
1 |
Tier 1 |
15% | 15% | None |
DOXIL 2mg/mL |
4 |
Tier 4 |
15% | 15% | None |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
15% | 15% | None |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
doxycycline 25 mg/5 ml susp |
1 |
Tier 1 |
15% | 15% | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Doxycycline 75mg/1 |
1 |
Tier 1 |
15% | 15% | None |
Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST |
1 |
Tier 1 |
15% | 15% | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
DOXYCYCLINE HYCLATE TAB 150MG |
1 |
Tier 1 |
15% | 15% | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL CAPS 10MG |
1 |
Tier 1 |
15% | 15% | P Q:60 /30Days |
DRONABINOL CAPS 2.5MG |
1 |
Tier 1 |
15% | 15% | P Q:60 /30Days |
DRONABINOL CAPS 5MG |
1 |
Tier 1 |
15% | 15% | P Q:60 /30Days |
DROXIA 200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DROXIA 300MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DROXIA 400MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DUETACT 30MG-2MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DUETACT 30MG-4MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
duramorph 0.5 mg/ml ampule |
1 |
Tier 1 |
15% | 15% | None |
duramorph 1 mg/ml ampule |
1 |
Tier 1 |
15% | 15% | None |