2014 Medicare Part D Plan Formulary Information |
Aetna Medicare Select Plan (HMO) (H4523-016-0)
Benefit Details
|
The Aetna Medicare Select Plan (HMO) (H4523-016-0) Formulary Drugs Starting with the Letter D in GUADALUPE County, TX: CMS MA Region 17 which includes: TX Plan Monthly Premium: $0.00 Deductible: $0 |
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 |
Generic |
$10.00 | $20.00 | None |
DACOGEN 50MG FOR INJECTION |
3 |
Non-Preferred Brand |
50% | 50% | None |
Daliresp 500ug/1 30 TABLET BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
50% | 50% | P |
DANAZOL 100MG CAPSULE |
3 |
Non-Preferred Brand |
50% | 50% | None |
DANAZOL 50MG CAPSULE |
3 |
Non-Preferred Brand |
50% | 50% | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
3 |
Non-Preferred Brand |
50% | 50% | None |
DANTROLENE SODIUM 100MG CAPSULE |
2 |
Preferred Brand |
25% | 25% | None |
DANTROLENE SODIUM 25MG CAPSULE |
2 |
Preferred Brand |
25% | 25% | None |
DANTROLENE SODIUM 50MG CAPSULE |
2 |
Preferred Brand |
25% | 25% | None |
DAPSONE TABLETS 100MG 30 BLPK |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE TABLETS 25MG 30 BLPK |
1 |
Generic |
$10.00 | $20.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Non-Preferred Brand |
50% | 50% | None |
DARAPRIM 25mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
50% | 50% | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
1 |
Generic |
$10.00 | $20.00 | None |
Decitabine 50 mg vial [Dacogen] |
1 |
Generic |
$10.00 | $20.00 | None |
DEGARELIX 240 MG INJ |
4 |
Specialty Tier |
33% | 33% | P Q:6 /365Days |
DENAVIR 1% CREAM |
3 |
Non-Preferred Brand |
50% | 50% | None |
DEPEN 250MG TITRATAB |
3 |
Non-Preferred Brand |
50% | 50% | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
3 |
Non-Preferred Brand |
50% | 50% | None |
DEPO-PROVERA 400MG/ML VIAL |
3 |
Non-Preferred Brand |
50% | 50% | None |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
3 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 10 MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
DESIPRAMINE 25MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
DESIPRAMINE 50MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
DESIPRAMINE 75 MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
2 |
Preferred Brand |
25% | 25% | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
2 |
Preferred Brand |
25% | 25% | None |
desloratadine 2.5 mg odt |
1 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
desloratadine 5 mg odt |
1 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
DESLORATADINE 5 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
DESMOPRESSIN AC 4MCG/ML VL |
1 |
Generic |
$10.00 | $20.00 | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
2 |
Preferred Brand |
25% | 25% | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT) |
2 |
Preferred Brand |
25% | 25% | None |
DESONIDE 0.05% OINTMENT |
1 |
Generic |
$10.00 | $20.00 | None |
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
1 |
Generic |
$10.00 | $20.00 | None |
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
desoximetasone 0.05% ointment |
3 |
Non-Preferred Brand |
50% | 50% | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Preferred Brand |
25% | 25% | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
50% | 50% | None |
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
50% | 50% | None |
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Preferred Brand |
25% | 25% | None |
DESVENLAFAXINE ER 100 MG TAB |
3 |
Non-Preferred Brand |
50% | 50% | S Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESVENLAFAXINE ER 50 MG TAB |
3 |
Non-Preferred Brand |
50% | 50% | S Q:1 /1Days |
DEXAMETHASONE 0.5MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
3 |
Non-Preferred Brand |
50% | 50% | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
Dexamethasone 10 mg/ml vial |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 1MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 2MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1 |
Generic |
$10.00 | $20.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Generic |
$10.00 | $20.00 | None |
dexrazoxane 500 mg vial |
1 |
Generic |
$10.00 | $20.00 | None |
DEXTROAMPHETAMINE 10MG TABLET |
1 |
Generic |
$10.00 | $20.00 | P Q:6 /1Days |
DEXTROAMPHETAMINE 5MG TABLET |
1 |
Generic |
$10.00 | $20.00 | P Q:6 /1Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Preferred Brand |
25% | 25% | P Q:2 /1Days |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Generic |
$10.00 | $20.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Generic |
$10.00 | $20.00 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Generic |
$10.00 | $20.00 | None |
Dextrose And Sodium Chloride 5; 0.9g/100mL; g/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONTAINER |
1 |
Generic |
$10.00 | $20.00 | None |
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g 12 CONTAINER in 1 CASE |
1 |
Generic |
$10.00 | $20.00 | 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 |
$10.00 | $20.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Generic |
$10.00 | $20.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Generic |
$10.00 | $20.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Generic |
$10.00 | $20.00 | None |
DEXTROSE INJECTION 10 250ML X 24 BOTPL |
1 |
Generic |
$10.00 | $20.00 | P |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Generic |
$10.00 | $20.00 | None |
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | Q:4 /1Days |
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | Q:10 /30Days |
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | Q:10 /30Days |
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | Q:10 /30Days |
Diazepam 2mg/1 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diazepam 5mg/1 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | Q:4 /1Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | Q:40 /1Days |
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER |
1 |
Generic |
$10.00 | $20.00 | Q:8 /1Days |
DICLOFENAC 25MG TABLET EC |
1 |
Generic |
$10.00 | $20.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
diclofenac-misoprost 50-0.2 tablet |
3 |
Non-Preferred Brand |
50% | 50% | None |
diclofenac-misoprost 75-0.2 tablet |
3 |
Non-Preferred Brand |
50% | 50% | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Generic |
$10.00 | $20.00 | None |
DICYCLOMINE 10MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | P |
DICYCLOMINE HCL 10MG/5ML SYRUP |
1 |
Generic |
$10.00 | $20.00 | P |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $20.00 | P |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2 |
Preferred Brand |
25% | 25% | None |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2 |
Preferred Brand |
25% | 25% | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
2 |
Preferred Brand |
25% | 25% | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
2 |
Preferred Brand |
25% | 25% | None |
DIFLORASONE 0.05% CREAM |
3 |
Non-Preferred Brand |
50% | 50% | None |
DIFLORASONE 0.05% OINTMENT |
3 |
Non-Preferred Brand |
50% | 50% | None |
DIFLUNISAL 500MG TABLET |
1 |
Generic |
$10.00 | $20.00 | 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 |
$10.00 | $20.00 | None |
Digoxin 125ug 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Digoxin 250ug 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Generic |
$10.00 | $20.00 | None |
DILANTIN 50MG INFATAB |
3 |
Non-Preferred Brand |
50% | 50% | None |
DILANTIN CAPSULES 30 MG EXTENDED RELEASE |
3 |
Non-Preferred Brand |
50% | 50% | None |
DILT XR 120 MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG |
1 |
Generic |
$10.00 | $20.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM 24HR CD 300 MG CAP |
1 |
Generic |
$10.00 | $20.00 | None |
diltiazem 25 mg/5 ml vial |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 30MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM 90MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM CD CAPSULES 120MG (90 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM CD CAPSULES 240MG (90 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM HCL 100MG VIAL |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM HCL 60MG ER CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM HCL 60MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
diltiazem hcl er 420 mg cap |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Diltiazem Hydrochloride 90mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
DILTIAZEM HYDROCHLORIDE ER 360MG CAPSULES |
1 |
Generic |
$10.00 | $20.00 | None |
DIPHTHERIA-TETANUS TOXOIDS-PED |
1 |
Generic |
$10.00 | $20.00 | None |
Dipyridamole 25mg/1 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Dipyridamole 75mg/1 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
DIPYRIDAMOLE TABLETS 50MG 100 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
Disulfiram 250mg/1 |
1 |
Generic |
$10.00 | $20.00 | None |
Disulfiram 500mg/1 |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM 125 MG CAP |
1 |
Generic |
$10.00 | $20.00 | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Generic |
$10.00 | $20.00 | None |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT |
2 |
Preferred Brand |
25% | 25% | None |
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT |
2 |
Preferred Brand |
25% | 25% | None |
DOCEFREZ 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | None |
DOCEFREZ 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | None |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
4 |
Specialty Tier |
33% | 33% | None |
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Specialty Tier |
33% | 33% | None |
DONEPEZIL HCL 23 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DONEPEZIL HYDROCHLORIDE 10 MG TABLETS |
1 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
DONEPEZIL HYDROCHLORIDE 5 MG TABLETS |
1 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Generic |
$10.00 | $20.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
1 |
Generic |
$10.00 | $20.00 | None |
Doxazosin 2mg 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
DOXAZOSIN MESYLATE TABLETS 8 MG |
1 |
Generic |
$10.00 | $20.00 | None |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
DOXEPIN 10MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 10MG/ML ORAL CONC |
1 |
Generic |
$10.00 | $20.00 | None |
DOXEPIN 75MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Generic |
$10.00 | $20.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE |
1 |
Generic |
$10.00 | $20.00 | P |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
doxycycline 25 mg/5 ml susp |
1 |
Generic |
$10.00 | $20.00 | None |
DOXYCYCLINE 50MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
Doxycycline 75mg/1 |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST |
1 |
Generic |
$10.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
DRONABINOL CAPS 10MG |
4 |
Specialty Tier |
33% | 33% | P Q:2 /1Days |
DRONABINOL CAPS 2.5MG |
1 |
Generic |
$10.00 | $20.00 | P Q:2 /1Days |
DRONABINOL CAPS 5MG |
1 |
Generic |
$10.00 | $20.00 | P Q:2 /1Days |
DROSPIRENONE-ETH ESTRADIOL TAB |
1 |
Generic |
$10.00 | $20.00 | None |
DROXIA 200MG CAPSULE |
3 |
Non-Preferred Brand |
50% | 50% | None |
DROXIA 300MG CAPSULE |
3 |
Non-Preferred Brand |
50% | 50% | None |
DROXIA 400MG CAPSULE |
3 |
Non-Preferred Brand |
50% | 50% | None |
DULERA INHALATION AEROSOL |
2 |
Preferred Brand |
25% | 25% | Q:13 /30Days |
DULERA INHALATION AEROSOL |
2 |
Preferred Brand |
25% | 25% | Q:13 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2 |
Preferred Brand |
25% | 25% | None |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
2 |
Preferred Brand |
25% | 25% | None |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
2 |
Preferred Brand |
25% | 25% | None |
DUREZOL 0.05% EYE DROPS |
2 |
Preferred Brand |
25% | 25% | None |