2015 Medicare Part D Plan Formulary Information |
Health Alliance Medicare PPO Basic Rx (PPO) (H1417-010-0)
Benefit Details
|
The Health Alliance Medicare PPO Basic Rx (PPO) (H1417-010-0) Formulary Drugs Starting with the Letter D in DOUGLAS County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $39.00 Deductible: $290 |
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 |
$0.00 | $30.00 | None |
DACOGEN 50MG FOR INJECTION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Daliresp 500ug/1 30 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
DALVANCE 500 MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
DANAZOL 100MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
DANAZOL 50MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
DANAZOL CAPSULES USP 200MG (100 CT) |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
DANTROLENE SODIUM 100MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE TABLETS 100MG 30 BLPK |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DAPSONE TABLETS 25MG 30 BLPK |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DARAPRIM 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DAUNOXOME 50 MG (2 MG/ML) VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DAYTRANA PATCH 1.1 MG/HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
DAYTRANA PATCH 1.6 MG/HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
DAYTRANA PATCH 2.2 MG/HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
DAYTRANA PATCH 3.3 MG/HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
DEBLITANE 0.35 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Decitabine 50 mg vial [Dacogen] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Delyla-28 tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DELZICOL DR 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DEMECLOCYCLINE HCL 150MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DEMECLOCYCLINE HCL 300MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Specialty Tier |
25% | 25% | None |
DENAVIR 1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
DEPEN 250MG TITRATAB |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DEPO-MEDROL 20MG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DESIPRAMINE 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESIPRAMINE 25MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESIPRAMINE 50MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESIPRAMINE 75 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESMOPRESSIN AC 4MCG/ML VL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DESMOPRESSIN ACETATE 0.1MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | 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 |
$0.00 | $30.00 | None |
DESOGESTR-ETH ESTRAD |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DESONIDE 0.05% OINTMENT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DESVENLAFAXINE ER 100 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DESVENLAFAXINE ER 50 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DEXAMETHASONE 0.5MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 1.5 MGTABLETS |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Dexamethasone 10 mg/ml vial |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE 1MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE 2MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE 4MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE 6MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
DEXILANT CAPSULES DELAYED RELEASE 60 MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE ER 10 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 15 MG CP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
Dexmethylphenidate er 20 mg cp |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 30 MG CP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 40 MG CP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 5 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:60 /30Days |
Dexrazoxane 500 MG Vial |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DEXTROAMP-AMPHET ER 10 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 15 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
DEXTROAMPHETAMINE 10MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:180 /30Days |
DEXTROAMPHETAMINE 5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:180 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:60 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:180 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:180 /30Days |
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 10%-1/4NS IV TUBEX |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE 10g/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTAINER |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE 5%-1/4NS IV SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE 5%-LR IV SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE 5%-NS IV SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Diazepam 2mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
Diazepam 5mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DIBENZYLINE 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DICLOFENAC 25MG TABLET EC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | 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 |
$0.00 | $30.00 | None |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Diclofenac Sodium 3% gel |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
diclofenac-misoprost 50-0.2 tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
diclofenac-misoprost 75-0.2 tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DICLOXACILLIN 250MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DICYCLOMINE 10MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
DIFLUNISAL 500MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Digitek 125 mcg tablet |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Digoxin 125ug 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DIHYDROERGOTAMINE 1 MG/ML AM |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:8 /23Days |
DILANTIN 50MG INFATAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DILANTIN CAPSULES 30 MG ER |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DILANTIN-125 SUS 125/5ML |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DILT XR 120 MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM 24HR ER 120 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM 24HR ER 240 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM 25 MG/5 ML VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DILTIAZEM 30 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 90 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DILTIAZEM ER 240MG CAPSULE SA |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 100MG VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 120MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DILTIAZEM HCL 180 MG ER 500 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 300 MG ER 90 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 360 MG ER CAPSULES |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 420 MG ER CAPSULES |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 60 MG ER CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DILTIAZEM HCL 60 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 90 MG ER CAPSULES 100 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DIPENTUM 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
diphenhydramine 50 mg/ml vial |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DIPHTHERIA-TETANUS TOXOIDS-PED |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Disulfiram 250mg/1 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Disulfiram 500mg/1 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DIVALPROEX SODIUM 125 MG CAP |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DIVALPROEX SODIUM 125MG TBEC |
1* |
Preferred Generic |
$0.00 | $30.00 | 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* |
Preferred Generic |
$0.00 | $30.00 | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DIVALPROEX SODIUM TABLETS ER 500MG 100 BOT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DOCEFREZ 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DONEPEZIL HCL 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DONEPEZIL HCL 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORIBAX 500 MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxazosin 2mg 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXAZOSIN MESYLATE 4MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXAZOSIN MESYLATE TABLETS 8 MG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXAZOSIN TABLET 1MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXEPIN 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
DOXEPIN 10MG/ML ORAL CONC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
DOXEPIN 75MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P S |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
Doxercalciferol 1 mcg capsule [HECTOROL] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
Doxercalciferol 4 mcg/2 ml amp [HECTOROL] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | P |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
doxycycline 25 mg/5 ml susp |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DOXYCYCLINE 50MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE 50MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxycycline 75mg/1 |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxycycline hyc 100 mg vial |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXYCYCLINE HYCLATE TAB 150MG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXYCYCLINE MONO 50 MG CAP |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Doxycycline Monohydrate IR 150mg/1 60 CAPSULE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE TABLETS 150MG 30 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
DRONABINOL CAPS 10MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
DRONABINOL CAPS 2.5MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
DRONABINOL CAPS 5MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
DROSPIRENONE-ETH ESTRADIOL TAB |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
DROXIA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DROXIA 300MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DROXIA 400MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DULERA INHALATION AEROSOL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DULERA INHALATION AEROSOL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:30 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | Q:60 /30Days |
duramorph 0.5 mg/ml ampule |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
duramorph 1 mg/ml ampule |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DUREZOL 0.05% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DUTOPROL 100-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DUTOPROL 25-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DUTOPROL 50-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
DYRENIUM 100MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
DYRENIUM 50MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Dysport 3001/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |