2017 Medicare Part D Plan Formulary Information |
Blue Medicare HMO Essential (HMO) (H3449-023-2)
Benefit Details
|
The Blue Medicare HMO Essential (HMO) (H3449-023-2) Formulary Drugs Starting with the Letter D in Cleveland County, NC: CMS MA Region 7 which includes: NC Plan Monthly Premium: $34.60 Deductible: $295 |
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 |
2 |
Generic |
$6.00 | $18.00 | None |
DAKLINZA 30 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
DAKLINZA 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
DAKLINZA 90 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
DALIRESP 500 MCG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
DALVANCE 500 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
DANAZOL 100MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
DANAZOL 50MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | P |
DANAZOL CAPSULES USP 200MG (100 CT) |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE TABLETS 25MG 30 BLPK |
2 |
Generic |
$6.00 | $18.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
DAPTOMYCIN 500 MG VIAL [Cubicin] |
5 |
Specialty Tier |
25% | N/A | None |
DARAPRIM 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
DARZALEX 100 MG/5 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
2 |
Generic |
$6.00 | $18.00 | None |
DEBLITANE 0.35 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
Decitabine 50 mg vial [Dacogen] |
5 |
Specialty Tier |
25% | N/A | None |
Delyla-28 tablet |
2 |
Generic |
$6.00 | $18.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Specialty Tier |
25% | N/A | None |
DEPEN 250MG TITRATAB |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Non-Preferred Brand |
50% | 50% | None |
DESCOVY 200-25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
DESIPRAMINE 10 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DESIPRAMINE 25MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DESIPRAMINE 50MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DESIPRAMINE 75 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
2 |
Generic |
$6.00 | $18.00 | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
2 |
Generic |
$6.00 | $18.00 | None |
Desmopressin ac 4 mcg/ml vial |
4 |
Non-Preferred Brand |
50% | 50% | None |
Desmopressin acetate 0.1 mg tb |
2 |
Generic |
$6.00 | $18.00 | None |
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Desmopressin acetate 0.2 mg tb |
2 |
Generic |
$6.00 | $18.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DESOGESTR-ETH ESTRAD |
2 |
Generic |
$6.00 | $18.00 | None |
Desvenlafaxine Succinate ER 100 mg [Pristiq] |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days |
Desvenlafaxine Succinate ER 25 mg tb [Pristiq] |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days |
Desvenlafaxine Succinate ER 50 mg tb [Pristiq] |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days |
DEXAMETHASONE 0.1% EYE DROP |
4 |
Non-Preferred Brand |
50% | 50% | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2 |
Generic |
$6.00 | $18.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 4MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 6MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
2 |
Generic |
$6.00 | $18.00 | None |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
Dexrazoxane 500 MG Vial |
5 |
Specialty Tier |
25% | N/A | None |
DEXTROAMP-AMPHET ER 10 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAP |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 30 MG CAP |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMPHETAMINE 10MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:180 /30Days |
DEXTROAMPHETAMINE 5MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:90 /30Days |
Dextrose 10%-water iv solution |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
2 |
Generic |
$6.00 | $18.00 | None |
Dextrose 5%-lr iv solution |
2 |
Generic |
$6.00 | $18.00 | None |
Dextrose 5%-ns iv solution |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
2 |
Generic |
$6.00 | $18.00 | None |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Non-Preferred Brand |
50% | 50% | Q:5 /30Days |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Non-Preferred Brand |
50% | 50% | Q:5 /30Days |
DIASTAT ACUDIAL 5-7.5-10 MG KT |
4 |
Non-Preferred Brand |
50% | 50% | Q:5 /30Days |
DIAZEPAM 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
Diazepam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
Diazepam 5mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
50% | 50% | P Q:1200 /30Days |
DICLOFENAC 25MG TABLET EC |
2 |
Generic |
$6.00 | $18.00 | Q:240 /30Days |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
2 |
Generic |
$6.00 | $18.00 | Q:120 /30Days |
Diclofenac Sodium 1% gel |
2 |
Generic |
$6.00 | $18.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
2 |
Generic |
$6.00 | $18.00 | Q:120 /30Days |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DICLOXACILLIN 250MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Digitek 125 mcg tablet |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Digitek 250 mcg tablet |
4 |
Non-Preferred Brand |
50% | 50% | P Q:30 /30Days |
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
50% | 50% | Q:150 /30Days |
Digoxin 125ug 100 TABLET BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Digoxin 250ug 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | P Q:30 /30Days |
DILANTIN CAPSULES 30 MG ER |
4 |
Non-Preferred Brand |
50% | 50% | None |
DILT XR 120 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM 24HR ER 120 MG CAP |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM 24HR ER 240 MG CAP |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM 30 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 90 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM ER 240MG CAPSULE SA |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM HCL 120MG ER CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM HCL 120MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM HCL 180 MG ER 500 CAPSULE BOTTLE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM HCL 300 MG ER 90 CAPSULE BOTTLE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM HCL 360 MG ER CAPSULES |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM HCL 60 MG ER CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DILTIAZEM HCL 60 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM HCL 90 MG ER CAPSULES 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Diltiazem hcl er 420 mg cap |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DIPENTUM 250 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
diphenhydramine 50 mg/ml vial |
2 |
Generic |
$6.00 | $18.00 | None |
DIPHTHERIA-TETANUS TOXOIDS-PED |
4 |
Non-Preferred Brand |
50% | 50% | None |
Disulfiram 250mg/1 |
2 |
Generic |
$6.00 | $18.00 | None |
Disulfiram 500mg/1 |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SODIUM 125 MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SODIUM 125MG TBEC |
2 |
Generic |
$6.00 | $18.00 | None |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Generic |
$6.00 | $18.00 | None |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SODIUM TABLETS ER 500MG 100 BOT |
2 |
Generic |
$6.00 | $18.00 | None |
DIVIGEL 0.5 MG GEL PACKET |
4 |
Non-Preferred Brand |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
25% | N/A | None |
Docetaxel 80 mg/4 ml vial |
5 |
Specialty Tier |
25% | N/A | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
4 |
Non-Preferred Brand |
50% | 50% | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
4 |
Non-Preferred Brand |
50% | 50% | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
4 |
Non-Preferred Brand |
50% | 50% | None |
DONEPEZIL HCL 10 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DONEPEZIL HCL 23 MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
DONEPEZIL HCL 5 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$6.00 | $18.00 | None |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$6.00 | $18.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxazosin 2mg 100 TABLET BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DOXAZOSIN MESYLATE 4MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DOXAZOSIN MESYLATE TABLETS 8 MG |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DOXAZOSIN TABLET 1MG (100 CT) |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DOXEPIN 10 MG/ML ORAL CONC |
4 |
Non-Preferred Brand |
50% | 50% | P |
DOXEPIN 10MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
50% | 50% | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | P |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
50% | 50% | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
4 |
Non-Preferred Brand |
50% | 50% | P |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE |
2 |
Generic |
$6.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxorubicin liposome 20mg/10ml |
5 |
Specialty Tier |
25% | N/A | P |
Doxy 100 vial |
4 |
Non-Preferred Brand |
50% | 50% | None |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE 50MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $18.00 | None |
DRONABINOL CAPS 10MG |
4 |
Non-Preferred Brand |
50% | 50% | P |
DRONABINOL CAPS 2.5MG |
4 |
Non-Preferred Brand |
50% | 50% | P |
DRONABINOL CAPS 5MG |
4 |
Non-Preferred Brand |
50% | 50% | P |
DROSP-EE-LEVOMEF 3-0.02-0.451 [Beyaz, Safyral] |
2 |
Generic |
$6.00 | $18.00 | None |
DROSPIRENONE-EE 3-0.02 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DROSPIRENONE-ETH ESTRADIOL TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DULERA INHALATION AEROSOL |
4 |
Non-Preferred Brand |
50% | 50% | Q:13 /30Days |
DULERA INHALATION AEROSOL |
4 |
Non-Preferred Brand |
50% | 50% | Q:13 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:60 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:60 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:60 /30Days |
duramorph 0.5 mg/ml ampule |
4 |
Non-Preferred Brand |
50% | 50% | P |
duramorph 1 mg/ml ampule |
4 |
Non-Preferred Brand |
50% | 50% | P |