Q1Medicare.com 2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

2014 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-148-0) Benefit Details
The First Health Part D Value Plus (PDP) (S5768-148-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $39.90 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter D Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter D Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DACOGEN 50MG FOR INJECTION	5	Specialty Tier	33%	N/A	P
Daliresp 500ug/1 30 TABLET BOTTLE, PLASTIC	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
DANAZOL 100MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DANAZOL 50MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DANAZOL CAPSULES USP 200MG (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
DANTROLENE SODIUM 100MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DANTROLENE SODIUM 25MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DANTROLENE SODIUM 50MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DAPSONE TABLETS 100MG 30 BLPK	3	Preferred Brand	$37.00	N/A	None
DAPSONE TABLETS 25MG 30 BLPK	3	Preferred Brand	$37.00	N/A	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	4	Non-Preferred Brand	$88.00	N/A	None
DARAPRIM 25mg/1 100 TABLET BOTTLE	3	Preferred Brand	$37.00	N/A	None
Decitabine 50 mg vial [Dacogen]	5	Specialty Tier	33%	N/A	P
DELZICOL DR 400 MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None
DEMECLOCYCLINE HCL 150MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
DEMECLOCYCLINE HCL 300MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
DEMSER CAPSULES 250MG (100 CT)	4	Non-Preferred Brand	$88.00	N/A	None
DENAVIR 1% CREAM	3	Preferred Brand	$37.00	N/A	Q:2 /30Days
DEPEN 250MG TITRATAB	3	Preferred Brand	$37.00	N/A	None
DEPO-ESTRADIOL 5MG/ML VIAL	4	Non-Preferred Brand	$88.00	N/A	None
DESIPRAMINE 10 MG TABLET	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DESIPRAMINE 25MG TABLET	1	Preferred Generic	$3.00	N/A	None
DESIPRAMINE 50MG TABLET	1	Preferred Generic	$3.00	N/A	None
DESIPRAMINE 75 MG TABLET	1	Preferred Generic	$3.00	N/A	None
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS	1	Preferred Generic	$3.00	N/A	None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT	1	Preferred Generic	$3.00	N/A	None
DESMOPRESSIN AC 4MCG/ML VL	2	Non-Preferred Generic	$11.00	N/A	None
DESMOPRESSIN ACETATE 0.1MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
DESONIDE 0.05% OINTMENT	2	Non-Preferred Generic	$11.00	N/A	None
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
desoximetasone 0.05% ointment	2	Non-Preferred Generic	$11.00	N/A	None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
DESVENLAFAXINE ER 100 MG TAB	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DESVENLAFAXINE ER 50 MG TAB	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DETROL LA 2MG CAPSULE SA	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DETROL LA 4MG CAPSULE SA	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DEXAMETHASONE 0.5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 0.5MG/0.5ML DROP	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXAMETHASONE 0.5MG/5ML ELX	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 0.75MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 1.5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
Dexamethasone 10 mg/ml vial	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 1MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 2MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 4MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE 6MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS	2	Non-Preferred Generic	$11.00	N/A	None
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD	2	Non-Preferred Generic	$11.00	N/A	None
DEXMETHYLPHENIDATE HCL 10MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXMETHYLPHENIDATE HCL 2.5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXMETHYLPHENIDATE HCL 5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROAMPHETAMINE 10MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROAMPHETAMINE 5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE 10%-1/4NS IV TUBEX	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE 2.5%-1/2NS IV SOLUTION	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE 5%-1/4NS IV SOLUTION	2	Non-Preferred Generic	$11.00	N/A	None
Dextrose And Sodium Chloride 5; 0.9g/100mL; g/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONTAINER	2	Non-Preferred Generic	$11.00	N/A	None
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g 12 CONTAINER in 1 CASE	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXTROSE IN SODIUM CHLORIDE INJECTION	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE INJECTION 10 250ML X 24 BOTPL	2	Non-Preferred Generic	$11.00	N/A	None
DEXTROSE INJECTION USP 5 4 X 100ML CTR	2	Non-Preferred Generic	$11.00	N/A	None
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$11.00	N/A	P Q:120 /30Days
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	P
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	P
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	P
Diazepam 2mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	P Q:120 /30Days
Diazepam 5mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$11.00	N/A	P Q:1200 /30Days
DIBENZYLINE 10MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None
DICLOFENAC 25MG TABLET EC	2	Non-Preferred Generic	$11.00	N/A	None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)	2	Non-Preferred Generic	$11.00	N/A	None
DICLOFENAC SODIUM 0.1% DROPS	2	Non-Preferred Generic	$11.00	N/A	None
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$11.00	N/A	None
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
diclofenac-misoprost 50-0.2 tablet	4	Non-Preferred Brand	$88.00	N/A	S
diclofenac-misoprost 75-0.2 tablet	4	Non-Preferred Brand	$88.00	N/A	S
DICLOXACILLIN 250MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DICLOXACILLIN SODIUM 500MG CAP	2	Non-Preferred Generic	$11.00	N/A	None
DICYCLOMINE 10MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	P
DICYCLOMINE HCL 10MG/5ML SYRUP	4	Non-Preferred Brand	$88.00	N/A	P
DICYCLOMINE HCL 20MG TABLET (500 CT)	4	Non-Preferred Brand	$88.00	N/A	P
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
DIDANOSINE 400MG CAPSULE DELAYED RELEASE	2	Non-Preferred Generic	$11.00	N/A	None
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT	2	Non-Preferred Generic	$11.00	N/A	None
DIFLORASONE 0.05% CREAM	2	Non-Preferred Generic	$11.00	N/A	None
DIFLORASONE 0.05% OINTMENT	2	Non-Preferred Generic	$11.00	N/A	None
DIFLUNISAL 500MG TABLET	2	Non-Preferred Generic	$11.00	N/A	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	Preferred Generic	$3.00	N/A	None
Digoxin 125ug 100 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
Digoxin 250ug 100 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
DIGOXIN INJECTION 500MCG 25 X 2ML AMP	1	Preferred Generic	$3.00	N/A	None
DILANTIN 50MG INFATAB	4	Non-Preferred Brand	$88.00	N/A	None
DILANTIN CAPSULES 30 MG EXTENDED RELEASE	4	Non-Preferred Brand	$88.00	N/A	None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)	4	Non-Preferred Brand	$88.00	N/A	None
DILANTIN-125 SUS 125/5ML	4	Non-Preferred Brand	$88.00	N/A	None
DILATRATE-SR 40 MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None
DILT XR 120 MG CAPSULE	1	Preferred Generic	$3.00	N/A	None
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM 24HR CD 300 MG CAP	1	Preferred Generic	$3.00	N/A	None
diltiazem 25 mg/5 ml vial	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM 30MG TABLET	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM 90MG TABLET	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM CD CAPSULES 120MG (90 CT)	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM CD CAPSULES 240MG (90 CT)	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM ER 240MG CAPSULE SA	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM HCL 120MG ER CAPSULE	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM HCL 120MG TABLET	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM HCL 60MG ER CAPSULE	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DILTIAZEM HCL 60MG TABLET	1	Preferred Generic	$3.00	N/A	None
diltiazem hcl er 420 mg cap	1	Preferred Generic	$3.00	N/A	None
Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	1	Preferred Generic	$3.00	N/A	None
Diltiazem Hydrochloride 90mg EXTENDED RELEASE 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
DILTIAZEM HYDROCHLORIDE ER 360MG CAPSULES	1	Preferred Generic	$3.00	N/A	None
DIOVAN 160MG TABLET	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DIOVAN 320MG TABLET	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DIOVAN 40MG TABLET	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
DIOVAN 80MG TABLET	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
DIPHENOXYLATE/ATROPINE LIQ	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIPHTHERIA-TETANUS TOXOIDS-PED	3	Preferred Brand	$37.00	N/A	None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
Disulfiram 250mg/1	1	Preferred Generic	$3.00	N/A	None
Disulfiram 500mg/1	1	Preferred Generic	$3.00	N/A	None
DIVALPROEX SODIUM 125 MG CAP	2	Non-Preferred Generic	$11.00	N/A	None
DIVALPROEX SODIUM 125MG TBEC	2	Non-Preferred Generic	$11.00	N/A	None
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT	2	Non-Preferred Generic	$11.00	N/A	None
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Divigel 1.0mg/g 30 PACKET per CARTON / 1.0 g in 1 PACKET	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
DOCEFREZ 1 KIT per CARTON	5	Specialty Tier	33%	N/A	P
DOCEFREZ 1 KIT per CARTON	5	Specialty Tier	33%	N/A	P
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE	5	Specialty Tier	33%	N/A	P
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS	5	Specialty Tier	33%	N/A	P
DONEPEZIL HCL 23 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
DONEPEZIL HYDROCHLORIDE 10 MG TABLETS	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
DONEPEZIL HYDROCHLORIDE 5 MG TABLETS	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL	4	Non-Preferred Brand	$88.00	N/A	Q:10 /30Days
Doxazosin 2mg 100 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
DOXAZOSIN MESYLATE 4MG TABLET	1	Preferred Generic	$3.00	N/A	None
DOXAZOSIN MESYLATE TABLETS 8 MG	1	Preferred Generic	$3.00	N/A	None
DOXAZOSIN TABLET 1MG (100 CT)	1	Preferred Generic	$3.00	N/A	None
DOXEPIN 10MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DOXEPIN 10MG/ML ORAL CONC	2	Non-Preferred Generic	$11.00	N/A	None
DOXEPIN 75MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DOXEPIN HCL 25MG CAPSULE (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT	2	Non-Preferred Generic	$11.00	N/A	None
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL]	4	Non-Preferred Brand	$88.00	N/A	None
Doxercalciferol 0.5 mcg capsule [HECTOROL]	4	Non-Preferred Brand	$88.00	N/A	None
Doxercalciferol 1 mcg capsule [HECTOROL]	4	Non-Preferred Brand	$88.00	N/A	None
Doxercalciferol 2.5 mcg capsule [HECTOROL]	4	Non-Preferred Brand	$88.00	N/A	None
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
DOXYCYCLINE 50MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	None
DOXYCYCLINE 50MG TABLET (100 CT)	4	Non-Preferred Brand	$88.00	N/A	None
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST	2	Non-Preferred Generic	$11.00	N/A	None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)	4	Non-Preferred Brand	$88.00	N/A	None
DOXYCYCLINE MONOHYDRATE 75MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DRONABINOL CAPS 10MG	4	Non-Preferred Brand	$88.00	N/A	P Q:60 /30Days
DRONABINOL CAPS 2.5MG	4	Non-Preferred Brand	$88.00	N/A	P Q:60 /30Days
DRONABINOL CAPS 5MG	4	Non-Preferred Brand	$88.00	N/A	P Q:60 /30Days
DROSPIRENONE-ETH ESTRADIOL TAB	4	Non-Preferred Brand	$88.00	N/A	None
DROXIA 200MG CAPSULE	3	Preferred Brand	$37.00	N/A	None
DROXIA 300MG CAPSULE	3	Preferred Brand	$37.00	N/A	None
DROXIA 400MG CAPSULE	3	Preferred Brand	$37.00	N/A	None
DULERA INHALATION AEROSOL	4	Non-Preferred Brand	$88.00	N/A	Q:13 /30Days
DULERA INHALATION AEROSOL	4	Non-Preferred Brand	$88.00	N/A	Q:13 /30Days
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta]	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta]	2	Non-Preferred Generic	$11.00	N/A	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta]	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
duramorph 0.5 mg/ml ampule	2	Non-Preferred Generic	$11.00	N/A	None
duramorph 1 mg/ml ampule	2	Non-Preferred Generic	$11.00	N/A	None
DUREZOL 0.05% EYE DROPS	4	Non-Preferred Brand	$88.00	N/A	None
DYRENIUM 100MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None
DYRENIUM 50MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D First Health Part D Value Plus (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2014 )

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