Q1Medicare.com 2015 Medicare Part D or Medicare Advantage Plan Formulary Browser

2015 Medicare Part D Plan Formulary Information
United American - Select (PDP) (S5755-088-0) Sanctioned Plan
The United American - Select (PDP) (S5755-088-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 17 which includes: IL Plan Monthly Premium: $30.80 Deductible: $320 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
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]	4	Non-Preferred Brand	24%	N/A	Q:60 /30Days
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta]	4	Non-Preferred Brand	24%	N/A	Q:60 /30Days
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta]	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

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D United American - Select (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 $320 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.