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AARP MedicareRx Saver Plus (PDP) (S5921-356-0)
Tier 1 (132)
Tier 2 (797)
Tier 3 (914)
Tier 4 (950)
Tier 5 (572)
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2016 Medicare Part D Plan Formulary Information
AARP MedicareRx Saver Plus (PDP) (S5921-356-0)
Benefit Details           
The AARP MedicareRx Saver Plus (PDP) (S5921-356-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $27.50 Deductible: $360 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 30%30%None
DAKLINZA 30 MG TABLET   5 Specialty Tier 25%25%P Q:28
/28Days
DAKLINZA 60 MG TABLET   5 Specialty Tier 25%25%P Q:28
/28Days
DAKLINZA 90 MG TABLET   5 Specialty Tier 25%25%P Q:28
/28Days
DALIRESP 500 MCG TABLET   4 Non-Preferred Brand 30%30%P Q:30
/30Days
DALVANCE 500 MG VIAL   5 Specialty Tier 25%25%P
DANAZOL 100MG CAPSULE   4 Non-Preferred Brand 30%30%None
DANAZOL 50MG CAPSULE   4 Non-Preferred Brand 30%30%None
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Brand 30%30%None
DANTROLENE SODIUM 100MG CAPSULE   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DANTROLENE SODIUM 25MG CAPSULE   2 Generic $2.00$0.00None
DANTROLENE SODIUM 50MG CAPSULE   2 Generic $2.00$0.00None
DAPSONE TABLETS 100MG 30 BLPK   3 Preferred Brand $23.00$64.00None
DAPSONE TABLETS 25MG 30 BLPK   3 Preferred Brand $23.00$64.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand $23.00$64.00None
DARAPRIM 25 MG TABLET   3 Preferred Brand $23.00$64.00None
DARZALEX 100 MG/5 ML VIAL   5 Specialty Tier 25%25%P
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL   4 Non-Preferred Brand 30%30%None
DEBLITANE 0.35 MG TABLET   3 Preferred Brand $23.00$64.00None
Decitabine 50 mg vial [Dacogen]   5 Specialty Tier 25%25%None
Delyla-28 tablet   3 Preferred Brand $23.00$64.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEMECLOCYCLINE HCL 150MG TABLET   4 Non-Preferred Brand 30%30%None
DEMECLOCYCLINE HCL 300MG TABLET   4 Non-Preferred Brand 30%30%None
DEMSER CAPSULES 250MG (100 CT)   5 Specialty Tier 25%25%None
DEPEN 250MG TITRATAB   5 Specialty Tier 25%25%None
DEPO-MEDROL 20MG/ML VIAL   4 Non-Preferred Brand 30%30%None
DEPO-PROVERA 400MG/ML VIAL   4 Non-Preferred Brand 30%30%None
DESCOVY 200-25 MG TABLET   5 Specialty Tier 25%25%Q:60
/30Days
DESIPRAMINE 10 MG TABLET   2 Generic $2.00$0.00None
DESIPRAMINE 25MG TABLET   2 Generic $2.00$0.00None
DESIPRAMINE 50MG TABLET   2 Generic $2.00$0.00None
DESIPRAMINE 75 MG TABLET   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS   2 Generic $2.00$0.00None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT   2 Generic $2.00$0.00None
DESMOPRESSIN AC 4MCG/ML VL   4 Non-Preferred Brand 30%30%None
DESMOPRESSIN ACETATE 0.1MG TABLET   2 Generic $2.00$0.00None
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL   3 Preferred Brand $23.00$64.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   2 Generic $2.00$0.00None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)   2 Generic $2.00$0.00None
DESOGESTR-ETH ESTRAD   2 Generic $2.00$0.00None
DESONIDE 0.05% OINTMENT   4 Non-Preferred Brand 30%30%None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Brand 30%30%None
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Brand 30%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 0.1% EYE DROP   2 Generic $2.00$0.00None
DEXAMETHASONE 0.5MG TABLET   2 Generic $2.00$0.00None
DEXAMETHASONE 0.5MG/0.5ML DROP   2 Generic $2.00$0.00None
DEXAMETHASONE 0.5MG/5ML ELX   2 Generic $2.00$0.00None
DEXAMETHASONE 0.75MG TABLET   2 Generic $2.00$0.00None
DEXAMETHASONE 1.5MG TABLET   2 Generic $2.00$0.00None
Dexamethasone 10 mg/ml vial   4 Non-Preferred Brand 30%30%None
DEXAMETHASONE 1MG TABLET   2 Generic $2.00$0.00None
DEXAMETHASONE 2MG TABLET   2 Generic $2.00$0.00None
DEXAMETHASONE 4MG TABLET   2 Generic $2.00$0.00None
DEXAMETHASONE 6MG TABLET   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD   4 Non-Preferred Brand 30%30%None
Dexedrine 10 mg tablet   4 Non-Preferred Brand 30%30%Q:180
/30Days
Dexedrine 5 mg tablet   4 Non-Preferred Brand 30%30%Q:180
/30Days
DEXILANT CAPSULES DELAYED RELEASE 30 MG   4 Non-Preferred Brand 30%30%Q:30
/30Days
DEXILANT CAPSULES DELAYED RELEASE 60 MG   4 Non-Preferred Brand 30%30%Q:30
/30Days
DEXMETHYLPHENIDATE ER 10 MG CAP   4 Non-Preferred Brand 30%30%None
DEXMETHYLPHENIDATE ER 15 MG CP   4 Non-Preferred Brand 30%30%None
Dexmethylphenidate er 20 mg cp   4 Non-Preferred Brand 30%30%None
DEXMETHYLPHENIDATE ER 30 MG CP   4 Non-Preferred Brand 30%30%None
DEXMETHYLPHENIDATE ER 40 MG CP   4 Non-Preferred Brand 30%30%None
DEXMETHYLPHENIDATE ER 5 MG CAP   4 Non-Preferred Brand 30%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXMETHYLPHENIDATE HCL 10MG TABLET   3 Preferred Brand $23.00$64.00Q:60
/30Days
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   3 Preferred Brand $23.00$64.00Q:60
/30Days
DEXMETHYLPHENIDATE HCL 5MG TABLET   3 Preferred Brand $23.00$64.00Q:60
/30Days
Dexrazoxane 500 MG Vial   5 Specialty Tier 25%25%P
DEXTROAMP-AMPHET ER 10 MG CAP   4 Non-Preferred Brand 30%30%Q:60
/30Days
DEXTROAMP-AMPHET ER 15 MG CAP   4 Non-Preferred Brand 30%30%Q:60
/30Days
DEXTROAMP-AMPHET ER 20 MG CAP   4 Non-Preferred Brand 30%30%Q:60
/30Days
DEXTROAMP-AMPHET ER 25 MG CAP   4 Non-Preferred Brand 30%30%Q:60
/30Days
DEXTROAMP-AMPHET ER 30 MG CAP   4 Non-Preferred Brand 30%30%Q:60
/30Days
DEXTROAMP-AMPHET ER 5 MG CAP   4 Non-Preferred Brand 30%30%Q:60
/30Days
DEXTROAMPHETAMINE 10MG TABLET   4 Non-Preferred Brand 30%30%Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMPHETAMINE 5MG TABLET   4 Non-Preferred Brand 30%30%Q:180
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   3 Preferred Brand $23.00$64.00Q:60
/30Days
DEXTROSE 10%-1/4NS IV TUBEX   4 Non-Preferred Brand 30%30%None
DEXTROSE 10g/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTAINER   4 Non-Preferred Brand 30%30%None
DEXTROSE 2.5%-1/2NS IV SOLUTION   4 Non-Preferred Brand 30%30%None
DEXTROSE 5%-1/4NS IV SOLUTION   4 Non-Preferred Brand 30%30%None
Dextrose 5%-lr iv solution   4 Non-Preferred Brand 30%30%None
Dextrose 5%-ns iv solution   4 Non-Preferred Brand 30%30%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Brand 30%30%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Brand 30%30%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   4 Non-Preferred Brand 30%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   4 Non-Preferred Brand 30%30%None
DEXTROSE INJECTION USP 5 4 X 100ML CTR   4 Non-Preferred Brand 30%30%None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Brand 30%30%None
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Brand 30%30%None
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Brand 30%30%None
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC   2 Generic $2.00$0.00Q:120
/30Days
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC   4 Non-Preferred Brand 30%30%None
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC   4 Non-Preferred Brand 30%30%None
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC   4 Non-Preferred Brand 30%30%None
Diazepam 2mg/1 100 TABLET BOTTLE   2 Generic $2.00$0.00Q:120
/30Days
Diazepam 5mg/1 100 TABLET BOTTLE   2 Generic $2.00$0.00Q: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 Generic $2.00$0.00None
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER   2 Generic $2.00$0.00Q:240
/30Days
DIBENZYLINE 10 MG CAPSULE   5 Specialty Tier 25%25%None
DICLOFENAC 25MG TABLET EC   2 Generic $2.00$0.00None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)   2 Generic $2.00$0.00None
DICLOFENAC SODIUM 0.1% DROPS   2 Generic $2.00$0.00None
Diclofenac Sodium 1% gel   3 Preferred Brand $23.00$64.00P
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Generic $2.00$0.00None
Diclofenac Sodium 3% gel   5 Specialty Tier 25%25%P
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)   2 Generic $2.00$0.00None
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOXACILLIN 250MG CAPSULE   2 Generic $2.00$0.00None
DICLOXACILLIN SODIUM 500MG CAP   2 Generic $2.00$0.00None
DICYCLOMINE 10MG CAPSULE   2 Generic $2.00$0.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   2 Generic $2.00$0.00None
DICYCLOMINE HCL 20MG TABLET (500 CT)   2 Generic $2.00$0.00None
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE   2 Generic $2.00$0.00Q:60
/30Days
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE   2 Generic $2.00$0.00Q:60
/30Days
DIDANOSINE 400MG CAPSULE DELAYED RELEASE   2 Generic $2.00$0.00Q:60
/30Days
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT   2 Generic $2.00$0.00Q:60
/30Days
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%25%P
DIFLUNISAL 500MG TABLET   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Digitek 125 mcg tablet   2 Generic $2.00$0.00None
Digitek 250 mcg tablet   2 Generic $2.00$0.00None
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER   4 Non-Preferred Brand 30%30%None
Digoxin 125ug 100 TABLET BOTTLE   2 Generic $2.00$0.00None
Digoxin 250ug 100 TABLET BOTTLE   2 Generic $2.00$0.00None
DIGOXIN INJECTION 500MCG 25 X 2ML AMP   4 Non-Preferred Brand 30%30%None
DIHYDROERGOTAMINE 1 MG/ML AM   4 Non-Preferred Brand 30%30%None
DILANTIN 50MG INFATAB   3 Preferred Brand $23.00$64.00None
DILANTIN CAPSULES 30 MG ER   3 Preferred Brand $23.00$64.00None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   3 Preferred Brand $23.00$64.00None
DILT XR 120 MG CAPSULE   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE   2 Generic $2.00$0.00None
DILTIAZEM 24HR ER 120 MG CAP   2 Generic $2.00$0.00None
DILTIAZEM 24HR ER 240 MG CAP   2 Generic $2.00$0.00None
DILTIAZEM 25 MG/5 ML VIAL   4 Non-Preferred Brand 30%30%None
DILTIAZEM 30 MG TABLET   2 Generic $2.00$0.00None
DILTIAZEM 90 MG TABLET   2 Generic $2.00$0.00None
DILTIAZEM ER 240MG CAPSULE SA   2 Generic $2.00$0.00None
DILTIAZEM HCL 100MG VIAL   4 Non-Preferred Brand 30%30%None
DILTIAZEM HCL 120MG TABLET   2 Generic $2.00$0.00None
DILTIAZEM HCL 300 MG ER 90 CAPSULE BOTTLE   2 Generic $2.00$0.00None
DILTIAZEM HCL 60 MG TABLET   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
diphenhydramine 50 mg/ml vial   4 Non-Preferred Brand 30%30%P
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE   4 Non-Preferred Brand 30%30%None
DIPHENOXYLATE/ATROPINE LIQ   4 Non-Preferred Brand 30%30%None
DIPHTHERIA-TETANUS TOXOIDS-PED   3 Preferred Brand $23.00$64.00None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)   2 Generic $2.00$0.00None
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)   2 Generic $2.00$0.00None
Disulfiram 250mg/1   2 Generic $2.00$0.00None
Disulfiram 500mg/1   2 Generic $2.00$0.00None
DIURIL 250MG/5ML SUSPENSION ORAL   3 Preferred Brand $23.00$64.00None
DIVALPROEX SODIUM 125 MG CAP   2 Generic $2.00$0.00None
DIVALPROEX SODIUM 125MG TBEC   2 Generic $2.00$0.00None
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   2 Generic $2.00$0.00None
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE   2 Generic $2.00$0.00None
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   2 Generic $2.00$0.00None
DIVALPROEX SODIUM TABLETS ER 500MG 100 BOT   2 Generic $2.00$0.00None
DOCEFREZ 1 KIT per CARTON   5 Specialty Tier 25%25%None
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier 25%25%None
Docetaxel 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS   5 Specialty Tier 25%25%None
Dolutegravir 25 mg oral tablet [TIVICAY]   4 Non-Preferred Brand 30%30%None
DONEPEZIL HCL 10 MG TABLET   2 Generic $2.00$0.00Q:60
/30Days
DONEPEZIL HCL 5 MG TABLET   2 Generic $2.00$0.00Q:30
/30Days
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2 Generic $2.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2 Generic $2.00$0.00Q:30
/30Days
DORIBAX 500 MG VIAL   4 Non-Preferred Brand 30%30%None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2 Generic $2.00$0.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   2 Generic $2.00$0.00None
Doxazosin 2mg 100 TABLET BOTTLE   2 Generic $2.00$0.00None
DOXAZOSIN MESYLATE 4MG TABLET   2 Generic $2.00$0.00None
DOXAZOSIN MESYLATE TABLETS 8 MG   2 Generic $2.00$0.00None
DOXAZOSIN TABLET 1MG (100 CT)   2 Generic $2.00$0.00None
DOXEPIN 10 MG/ML ORAL CONC   2 Generic $2.00$0.00None
DOXEPIN 10MG CAPSULE   2 Generic $2.00$0.00None
DOXEPIN 5% CREAM   3 Preferred Brand $23.00$64.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN 75MG CAPSULE   2 Generic $2.00$0.00None
DOXEPIN HCL 25MG CAPSULE (100 CT)   2 Generic $2.00$0.00None
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   2 Generic $2.00$0.00None
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK   2 Generic $2.00$0.00None
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   2 Generic $2.00$0.00None
Doxercalciferol 0.5 mcg capsule [HECTOROL]   4 Non-Preferred Brand 30%30%P Q:90
/30Days
Doxercalciferol 1 mcg capsule [HECTOROL]   4 Non-Preferred Brand 30%30%P Q:240
/30Days
Doxercalciferol 2.5 mcg capsule [HECTOROL]   4 Non-Preferred Brand 30%30%P Q:120
/30Days
Doxercalciferol 4 mcg/2 ml amp [HECTOROL]   4 Non-Preferred Brand 30%30%P
DOXIL 2mg/mL   5 Specialty Tier 25%25%None
Doxorubicin Hydrochloride 10 ml Liposome 2 mg/ml injection   4 Non-Preferred Brand 30%30%None
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   4 Non-Preferred Brand 30%30%P
Doxorubicin liposome 20mg/10ml   5 Specialty Tier 25%25%None
Doxy 100 vial   4 Non-Preferred Brand 30%30%None
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE   4 Non-Preferred Brand 30%30%None
doxycycline 25 mg/5 ml susp   3 Preferred Brand $23.00$64.00None
DOXYCYCLINE 50MG CAPSULE   3 Preferred Brand $23.00$64.00None
DOXYCYCLINE 50MG TABLET (100 CT)   4 Non-Preferred Brand 30%30%None
Doxycycline 75mg/1   4 Non-Preferred Brand 30%30%None
Doxycycline hyc 100 mg vial   4 Non-Preferred Brand 30%30%None
Doxycycline hyc dr 200 mg tablet   4 Non-Preferred Brand 30%30%None
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST   3 Preferred Brand $23.00$64.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   4 Non-Preferred Brand 30%30%None
DOXYCYCLINE MONO 100 MG CAP   4 Non-Preferred Brand 30%30%None
DOXYCYCLINE MONO 100 MG TABLET   4 Non-Preferred Brand 30%30%None
DOXYCYCLINE MONO 50 MG CAP   4 Non-Preferred Brand 30%30%None
DOXYCYCLINE MONO 50 MG TABLET   4 Non-Preferred Brand 30%30%None
DOXYCYCLINE MONOHYDRATE 75MG TABLET   4 Non-Preferred Brand 30%30%None
Doxycycline Monohydrate IR 150mg/1 60 CAPSULE in 1 BOTTLE   4 Non-Preferred Brand 30%30%None
DOXYCYCLINE TABLETS 150MG 30 BOT   4 Non-Preferred Brand 30%30%None
DRONABINOL CAPS 10MG   4 Non-Preferred Brand 30%30%P Q:120
/30Days
DRONABINOL CAPS 2.5MG   4 Non-Preferred Brand 30%30%P Q:120
/30Days
DRONABINOL CAPS 5MG   4 Non-Preferred Brand 30%30%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DROSPIRENONE-EE 3-0.02 MG TAB   3 Preferred Brand $23.00$64.00None
DROSPIRENONE-ETH ESTRADIOL TAB   3 Preferred Brand $23.00$64.00None
DROXIA 200MG CAPSULE   3 Preferred Brand $23.00$64.00None
DROXIA 300MG CAPSULE   3 Preferred Brand $23.00$64.00None
DROXIA 400MG CAPSULE   3 Preferred Brand $23.00$64.00None
DUAVEE 0.45-20 MG TABLET   4 Non-Preferred Brand 30%30%None
DULERA INHALATION AEROSOL   4 Non-Preferred Brand 30%30%P
DULERA INHALATION AEROSOL   4 Non-Preferred Brand 30%30%P
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta]   2 Generic $2.00$0.00Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta]   2 Generic $2.00$0.00Q:60
/30Days
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta]   2 Generic $2.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
duramorph 0.5 mg/ml ampule   4 Non-Preferred Brand 30%30%None
duramorph 1 mg/ml ampule   4 Non-Preferred Brand 30%30%None
DUREZOL 0.05% EYE DROPS   3 Preferred Brand $23.00$64.00None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D AARP MedicareRx Saver 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 $360 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 $3310) 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 2016 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.