2015 Medicare Part D Plan Formulary Information |
United American - Select (PDP) (S5755-102-0)
Sanctioned Plan
 |
The United American - Select (PDP) (S5755-102-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $41.50 Deductible: $320 Qualifies for LIS: Yes |
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  |
4 |
Non-Preferred Brand |
24% | N/A | P |
Daliresp 500ug/1 30 TABLET BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DANAZOL 100MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DANAZOL 50MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DANAZOL CAPSULES USP 200MG (100 CT)  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DANTROLENE SODIUM 100MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DANTROLENE SODIUM 25MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DANTROLENE SODIUM 50MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DAPSONE TABLETS 100MG 30 BLPK  |
3 |
Preferred Brand |
14% | 19% | None |
DAPSONE TABLETS 25MG 30 BLPK  |
3 |
Preferred Brand |
14% | 19% | 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  |
3 |
Preferred Brand |
14% | 19% | None |
DARAPRIM 25 MG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL  |
3 |
Preferred Brand |
14% | 19% | P |
DEBLITANE 0.35 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
Delyla-28 tablet  |
3 |
Preferred Brand |
14% | 19% | None |
DELZICOL DR 400 MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DEMSER CAPSULES 250MG (100 CT)  |
5 |
Specialty Tier |
25% | N/A | None |
DENAVIR 1% CREAM  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DEPEN 250MG TITRATAB  |
5 |
Specialty Tier |
25% | N/A | None |
DEPO-PROVERA 400MG/ML VIAL  |
4 |
Non-Preferred Brand |
24% | N/A | P |
DESIPRAMINE 10 MG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 25MG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESIPRAMINE 50MG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESIPRAMINE 75 MG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESMOPRESSIN AC 4MCG/ML VL  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESMOPRESSIN ACETATE 0.1MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)  |
3 |
Preferred Brand |
14% | 19% | None |
DESOGESTR-ETH ESTRAD  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONIDE 0.05% OINTMENT  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
24% | N/A | None |
desoximetasone 0.05% ointment  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DEXAMETHASONE 0.5MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP  |
3 |
Preferred Brand |
14% | 19% | None |
DEXAMETHASONE 0.5MG/5ML ELX  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.75MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 1.5MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Dexamethasone 10 mg/ml vial  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXAMETHASONE 1MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 2MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 4MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 6MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
DEXILANT CAPSULES DELAYED RELEASE 60 MG  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Dexrazoxane 500 MG Vial  |
5 |
Specialty Tier |
25% | N/A | P |
DEXTROAMP-AMPHET ER 10 MG CAP  |
4 |
Non-Preferred Brand |
24% | N/A | Q:90 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAP  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAP  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAP  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP  |
4 |
Non-Preferred Brand |
24% | N/A | Q:90 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)  |
3 |
Preferred Brand |
14% | 19% | Q:180 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX  |
3 |
Preferred Brand |
14% | 19% | None |
DEXTROSE 10g/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTAINER  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 5%-1/4NS IV SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE 5%-LR IV SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE 5%-NS IV SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DEXTROSE INJECTION USP 5 4 X 100ML CTR  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC  |
1 |
Preferred Generic |
$0.00 | $0.00 | P Q:120 /30Days |
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Diazepam 2mg/1 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | P Q:120 /30Days |
Diazepam 5mg/1 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | P Q:120 /30Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC  |
3 |
Preferred Brand |
14% | 19% | P Q:1200 /30Days |
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER  |
3 |
Preferred Brand |
14% | 19% | P Q:240 /30Days |
DICLOFENAC 25MG TABLET EC  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DICLOFENAC SODIUM 0.1% DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC  |
3 |
Preferred Brand |
14% | 19% | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOXACILLIN 250MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DICLOXACILLIN SODIUM 500MG CAP  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DICYCLOMINE 10MG CAPSULE  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP  |
3 |
Preferred Brand |
14% | 19% | None |
DICYCLOMINE HCL 20MG TABLET (500 CT)  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE  |
5 |
Specialty Tier |
25% | N/A | None |
DIFLORASONE 0.05% CREAM  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLORASONE 0.05% OINTMENT  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DIFLUNISAL 500MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
Digitek 125 mcg tablet  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
Digitek 250 mcg tablet  |
3 |
Preferred Brand |
14% | 19% | P |
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER  |
3 |
Preferred Brand |
14% | 19% | P |
Digoxin 125ug 100 TABLET BOTTLE  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
Digoxin 250ug 100 TABLET BOTTLE  |
3 |
Preferred Brand |
14% | 19% | P |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP  |
3 |
Preferred Brand |
14% | 19% | None |
DIHYDROERGOTAMINE 1 MG/ML AM  |
3 |
Preferred Brand |
14% | 19% | None |
DILANTIN 50MG INFATAB  |
3 |
Preferred Brand |
14% | 19% | None |
DILANTIN CAPSULES 30 MG ER  |
3 |
Preferred Brand |
14% | 19% | 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)  |
3 |
Preferred Brand |
14% | 19% | None |
DILANTIN-125 SUS 125/5ML  |
3 |
Preferred Brand |
14% | 19% | None |
DILT XR 120 MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM 24HR ER 120 MG CAP  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM 24HR ER 240 MG CAP  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM 25 MG/5 ML VIAL  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DILTIAZEM 30 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DILTIAZEM 90 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DILTIAZEM ER 240MG CAPSULE SA  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM HCL 120MG ER CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 120MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DILTIAZEM HCL 180 MG ER 500 CAPSULE BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM HCL 300 MG ER 90 CAPSULE BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM HCL 360 MG ER CAPSULES  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM HCL 420 MG ER CAPSULES  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM HCL 60 MG ER CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
DILTIAZEM HCL 60 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
DILTIAZEM HCL 90 MG ER CAPSULES 100 CAPSULE BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
DIPENTUM 250 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | None |
diphenhydramine 50 mg/ml vial  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPHENOXYLATE/ATROPINE LIQ  |
3 |
Preferred Brand |
14% | 19% | None |
DIPHTHERIA-TETANUS TOXOIDS-PED  |
3 |
Preferred Brand |
14% | 19% | P |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)  |
4 |
Non-Preferred Brand |
24% | N/A | P |
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)  |
4 |
Non-Preferred Brand |
24% | N/A | P |
Disulfiram 250mg/1  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Disulfiram 500mg/1  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DIURIL 250MG/5ML SUSPENSION ORAL  |
3 |
Preferred Brand |
14% | 19% | None |
DIVALPROEX SODIUM 125 MG CAP  |
3 |
Preferred Brand |
14% | 19% | None |
DIVALPROEX SODIUM 125MG TBEC  |
3 |
Preferred Brand |
14% | 19% | None |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DIVALPROEX SODIUM TABLETS ER 500MG 100 BOT  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS  |
5 |
Specialty Tier |
25% | N/A | P |
DONEPEZIL HCL 10 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
DONEPEZIL HCL 23 MG TABLET  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DONEPEZIL HCL 5 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK  |
4 |
Non-Preferred Brand |
24% | N/A | Q:30 /30Days |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR  |
3 |
Preferred Brand |
14% | 19% | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxazosin 2mg 100 TABLET BOTTLE  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
DOXAZOSIN MESYLATE 4MG TABLET  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
DOXAZOSIN MESYLATE TABLETS 8 MG  |
3 |
Preferred Brand |
14% | 19% | None |
DOXAZOSIN TABLET 1MG (100 CT)  |
3 |
Preferred Brand |
14% | 19% | Q:30 /30Days |
DOXEPIN 10MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | P |
DOXEPIN 10MG/ML ORAL CONC  |
4 |
Non-Preferred Brand |
24% | N/A | P |
DOXEPIN 75MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | P |
DOXEPIN HCL 25MG CAPSULE (100 CT)  |
4 |
Non-Preferred Brand |
24% | N/A | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE  |
4 |
Non-Preferred Brand |
24% | N/A | P |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK  |
4 |
Non-Preferred Brand |
24% | N/A | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT  |
4 |
Non-Preferred Brand |
24% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE  |
3 |
Preferred Brand |
14% | 19% | P |
Doxy 100 vial  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE 50MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE 50MG TABLET (100 CT)  |
3 |
Preferred Brand |
14% | 19% | None |
Doxycycline hyc 100 mg vial  |
4 |
Non-Preferred Brand |
24% | N/A | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE MONO 100 MG CAP  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE MONO 100 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE MONO 50 MG CAP  |
3 |
Preferred Brand |
14% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE MONO 50 MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET  |
3 |
Preferred Brand |
14% | 19% | None |
DOXYCYCLINE TABLETS 150MG 30 BOT  |
3 |
Preferred Brand |
14% | 19% | None |
DRONABINOL CAPS 10MG  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
DRONABINOL CAPS 2.5MG  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:60 /30Days |
DRONABINOL CAPS 5MG  |
4 |
Non-Preferred Brand |
24% | N/A | P Q:60 /30Days |
DROSPIRENONE-ETH ESTRADIOL TAB  |
3 |
Preferred Brand |
14% | 19% | None |
DROXIA 200MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
DROXIA 300MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
DROXIA 400MG CAPSULE  |
3 |
Preferred Brand |
14% | 19% | None |
DULERA INHALATION AEROSOL  |
4 |
Non-Preferred Brand |
24% | N/A | Q:13 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULERA INHALATION AEROSOL  |
4 |
Non-Preferred Brand |
24% | N/A | Q:13 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] ![Compare how all Medicare Part D PDP plans in ID cover DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] ![Compare how all Medicare Part D PDP plans in ID cover DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] ![Compare how all Medicare Part D PDP plans in ID cover DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
24% | N/A | Q:60 /30Days |
duramorph 0.5 mg/ml ampule  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | P |
duramorph 1 mg/ml ampule  |
2 |
Non-Preferred Generic |
$3.00 | $33.00 | P |
DUREZOL 0.05% EYE DROPS  |
3 |
Preferred Brand |
14% | 19% | None |
DYRENIUM 100MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |
DYRENIUM 50MG CAPSULE  |
4 |
Non-Preferred Brand |
24% | N/A | None |