2017 Medicare Part D Plan Formulary Information |
MCS Classicare MediCa$h (HMO) (H5577-014-0)
Benefit Details
|
The MCS Classicare MediCa$h (HMO) (H5577-014-0) Formulary Drugs Starting with the Letter D in Yauco County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $400 |
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 |
D-AMPHETAMINE ER 15 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | Q:120 /30Days |
DACARBAZINE 200MG VIAL |
1 |
Tier 1 |
25% | N/A | P |
DALIRESP 500 MCG TABLET |
4 |
Tier 4 |
25% | N/A | P |
DANAZOL 100MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
DANAZOL 50MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
2 |
Tier 2 |
25% | N/A | None |
DANTROLENE SODIUM 100MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
DANTROLENE SODIUM 25MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
DANTROLENE SODIUM 50MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE TABLETS 25MG 30 BLPK |
2 |
Tier 2 |
25% | N/A | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Tier 3 |
25% | N/A | None |
DAPTOMYCIN 500 MG VIAL [Cubicin] |
2 |
Tier 2 |
25% | N/A | P |
DARAPRIM 25 MG TABLET |
3 |
Tier 3 |
25% | N/A | P |
DARIFENACIN ER 15 MG TABLET [Enablex] |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
DARIFENACIN ER 7.5 MG TABLET [Enablex] |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
DARZALEX 100 MG/5 ML VIAL |
3 |
Tier 3 |
25% | N/A | P |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
1 |
Tier 1 |
25% | N/A | P |
DEBLITANE 0.35 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Decitabine 50 mg vial [Dacogen] |
5 |
Tier 5 |
25% | N/A | P |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
4 |
Tier 4 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Delyla-28 tablet |
2 |
Tier 2 |
25% | N/A | None |
DEMECLOCYCLINE HCL 150MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
DEMECLOCYCLINE HCL 300MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Tier 5 |
25% | N/A | None |
DENAVIR 1% CREAM |
3 |
Tier 3 |
25% | N/A | None |
DEPEN 250MG TITRATAB |
4 |
Tier 4 |
25% | N/A | None |
DEPO-PROVERA 400MG/ML VIAL |
3 |
Tier 3 |
25% | N/A | P |
DESCOVY 200-25 MG TABLET |
5 |
Tier 5 |
25% | N/A | None |
DESIPRAMINE 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DESIPRAMINE 25MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
DESIPRAMINE 50MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 75 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
2 |
Tier 2 |
25% | N/A | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
2 |
Tier 2 |
25% | N/A | None |
DESLORATADINE 2.5 MG ODDT |
2 |
Tier 2 |
25% | N/A | None |
DESLORATADINE 5 MG ODDT |
2 |
Tier 2 |
25% | N/A | None |
DESLORATADINE 5 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Desmopressin ac 4 mcg/ml vial |
1 |
Tier 1 |
25% | N/A | P |
Desmopressin acetate 0.1 mg tb |
2 |
Tier 2 |
25% | N/A | None |
Desmopressin acetate 0.2 mg tb |
2 |
Tier 2 |
25% | N/A | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
2 |
Tier 2 |
25% | N/A | None |
DESOGESTR-ETH ESTRAD |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONIDE 0.05% CREAM |
2 |
Tier 2 |
25% | N/A | None |
DESONIDE 0.05% OINTMENT |
2 |
Tier 2 |
25% | N/A | None |
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
25% | N/A | None |
Desoximetasone 0.0005 MG/MG Topical Ointment |
1 |
Tier 1 |
25% | N/A | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
25% | N/A | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
25% | N/A | None |
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE |
2 |
Tier 2 |
25% | N/A | None |
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
25% | N/A | None |
DESVENLAFAXINE ER 100 MG TAB |
2 |
Tier 2 |
25% | N/A | S Q:120 /30Days |
DESVENLAFAXINE ER 50 MG TAB |
2 |
Tier 2 |
25% | N/A | S Q:30 /30Days |
Desvenlafaxine Succinate ER 100 mg [Pristiq] |
2 |
Tier 2 |
25% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Desvenlafaxine Succinate ER 25 mg tb [Pristiq] |
2 |
Tier 2 |
25% | N/A | S Q:60 /30Days |
Desvenlafaxine Succinate ER 50 mg tb [Pristiq] |
2 |
Tier 2 |
25% | N/A | S Q:30 /30Days |
DEXAMETHASONE 0.1% EYE DROP |
2 |
Tier 2 |
25% | N/A | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 0.5MG/5ML ELX |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Dexamethasone 10 mg/ml vial |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 1MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 2MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 4MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE 6MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
1 |
Tier 1 |
25% | N/A | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
3 |
Tier 3 |
25% | N/A | S |
DEXILANT CAPSULES DELAYED RELEASE 60 MG |
3 |
Tier 3 |
25% | N/A | S |
DEXMETHYLPHENIDATE ER 15 MG CP |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 30 MG CP |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 40 MG CP |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Dexrazoxane 500 MG Vial |
5 |
Tier 5 |
25% | N/A | P |
DEXTROAMP-AMPHETAMIN 20 MG TAB |
2 |
Tier 2 |
25% | N/A | Q:90 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX |
1 |
Tier 1 |
25% | N/A | P |
Dextrose 10%-water iv solution |
1 |
Tier 1 |
25% | N/A | P |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Tier 1 |
25% | N/A | P |
DEXTROSE 5%-1/4NS IV SOLUTION |
1 |
Tier 1 |
25% | N/A | P |
Dextrose 5%-lr iv solution |
1 |
Tier 1 |
25% | N/A | P |
Dextrose 5%-ns iv solution |
1 |
Tier 1 |
25% | N/A | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
25% | N/A | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Tier 1 |
25% | N/A | P |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Tier 1 |
25% | N/A | P |
DEXTROSE INJECTION USP 5 4 X 100ML CTR |
1 |
Tier 1 |
25% | N/A | P |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Tier 4 |
25% | N/A | None |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Tier 4 |
25% | N/A | None |
DIASTAT ACUDIAL 5-7.5-10 MG KT |
4 |
Tier 4 |
25% | N/A | None |
DIAZEPAM 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:120 /30Days |
Diazepam 2mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
Diazepam 5mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | N/A | Q:1200 /30Days |
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER per CARTON / 30 mL in 1 BOTTLE, DROPPER |
1 |
Tier 1 |
25% | N/A | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC 25MG TABLET EC |
2 |
Tier 2 |
25% | N/A | None |
DICLOFENAC POTASSIUM 50MG TABLET (500 CT) |
2 |
Tier 2 |
25% | N/A | None |
DICLOFENAC SODIUM 0.1% DROPS |
1 |
Tier 1 |
25% | N/A | Q:5 /25Days |
Diclofenac Sodium 1% gel |
2 |
Tier 2 |
25% | N/A | None |
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | N/A | None |
Diclofenac Sodium 3% gel |
5 |
Tier 5 |
25% | N/A | None |
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT) |
1 |
Tier 1 |
25% | N/A | None |
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
diclofenac-misoprost 50-0.2 tablet |
2 |
Tier 2 |
25% | N/A | None |
diclofenac-misoprost 75-0.2 tablet |
2 |
Tier 2 |
25% | N/A | None |
DICLOXACILLIN 250MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOXACILLIN SODIUM 500MG CAP |
1 |
Tier 1 |
25% | N/A | None |
DICYCLOMINE 10MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
2 |
Tier 2 |
25% | N/A | None |
DICYCLOMINE HCL 20MG TABLET (500 CT) |
1 |
Tier 1 |
25% | N/A | None |
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
DIDANOSINE 400MG CAPSULE DELAYED RELEASE |
2 |
Tier 2 |
25% | N/A | None |
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT |
1 |
Tier 1 |
25% | N/A | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Tier 5 |
25% | N/A | S Q:20 /10Days |
DIFLORASONE 0.05% CREAM |
2 |
Tier 2 |
25% | N/A | None |
DIFLORASONE 0.05% OINTMENT |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLUNISAL 500MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Digitek 125 mcg tablet |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
Digitek 250 mcg tablet |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER |
2 |
Tier 2 |
25% | N/A | None |
Digoxin 125ug 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
Digoxin 250ug 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |
DIGOXIN INJECTION 500MCG 25 X 2ML AMP |
1 |
Tier 1 |
25% | N/A | P |
DIHYDROERGOTAMINE 1 MG/ML AM |
2 |
Tier 2 |
25% | N/A | Q:24 /28Days |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
2 |
Tier 2 |
25% | N/A | Q:28 /28Days |
DILT XR 120 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 24HR ER 120 MG CAP |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM 24HR ER 240 MG CAP |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM 30 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM 90 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM ER 240MG CAPSULE SA |
2 |
Tier 2 |
25% | N/A | None |
DILTIAZEM HCL 120MG ER CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
DILTIAZEM HCL 120MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM HCL 180 MG ER 500 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM HCL 300 MG ER 90 CAPSULE BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
DILTIAZEM HCL 360 MG ER CAPSULES |
2 |
Tier 2 |
25% | N/A | None |
DILTIAZEM HCL 60 MG ER CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 60 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DILTIAZEM HCL 90 MG ER CAPSULES 100 CAPSULE BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
Diltiazem hcl er 420 mg cap |
2 |
Tier 2 |
25% | N/A | None |
DIPENTUM 250 MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
diphenhydramine 50 mg/ml vial |
1 |
Tier 1 |
25% | N/A | P |
DIPHTHERIA-TETANUS TOXOIDS-PED |
3 |
Tier 3 |
25% | N/A | None |
Disulfiram 250mg/1 |
2 |
Tier 2 |
25% | N/A | None |
Disulfiram 500mg/1 |
2 |
Tier 2 |
25% | N/A | None |
DIVALPROEX SODIUM 125 MG CAP |
2 |
Tier 2 |
25% | N/A | None |
DIVALPROEX SODIUM 125MG TBEC |
1 |
Tier 1 |
25% | N/A | None |
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT |
2 |
Tier 2 |
25% | N/A | None |
DIVALPROEX SODIUM TABLETS ER 500MG 100 BOT |
2 |
Tier 2 |
25% | N/A | None |
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE |
5 |
Tier 5 |
25% | N/A | P |
Docetaxel 80 mg/4 ml vial |
5 |
Tier 5 |
25% | N/A | P |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
2 |
Tier 2 |
25% | N/A | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
2 |
Tier 2 |
25% | N/A | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
2 |
Tier 2 |
25% | N/A | None |
DONEPEZIL HCL 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:31 /31Days |
DONEPEZIL HCL 23 MG TABLET |
2 |
Tier 2 |
25% | N/A | Q:31 /31Days |
DONEPEZIL HCL 5 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Tier 1 |
25% | N/A | Q:31 /31Days |
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Tier 1 |
25% | N/A | Q:31 /31Days |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
1 |
Tier 1 |
25% | N/A | Q:10 /25Days |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
1 |
Tier 1 |
25% | N/A | Q:10 /25Days |
Doxazosin 2mg 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
DOXAZOSIN MESYLATE 4MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
DOXAZOSIN MESYLATE TABLETS 8 MG |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
DOXAZOSIN TABLET 1MG (100 CT) |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
DOXEPIN 10 MG/ML ORAL CONC |
1 |
Tier 1 |
25% | N/A | P |
DOXEPIN 10MG CAPSULE |
1 |
Tier 1 |
25% | N/A | P |
DOXEPIN 75MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
25% | N/A | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
25% | N/A | P |
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Tier 2 |
25% | N/A | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
2 |
Tier 2 |
25% | N/A | P |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
2 |
Tier 2 |
25% | N/A | P |
Doxercalciferol 1 mcg capsule [HECTOROL] |
5 |
Tier 5 |
25% | N/A | P |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
5 |
Tier 5 |
25% | N/A | P |
Doxercalciferol 4 mcg/2 ml amp [HECTOROL] |
1 |
Tier 1 |
25% | N/A | P |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE |
2 |
Tier 2 |
25% | N/A | P |
Doxorubicin liposome 20mg/10ml |
5 |
Tier 5 |
25% | N/A | P |
Doxy 100 vial |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
doxycycline 25 mg/5 ml susp |
1 |
Tier 1 |
25% | N/A | None |
DOXYCYCLINE 50MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
DOXYCYCLINE 50MG TABLET (100 CT) |
2 |
Tier 2 |
25% | N/A | None |
Doxycycline 75mg/1 |
1 |
Tier 1 |
25% | N/A | None |
Doxycycline hyc dr 200 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Doxycycline hyc dr 50 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
25% | N/A | None |
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE BOTTLE, PLAST |
2 |
Tier 2 |
25% | N/A | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
1 |
Tier 1 |
25% | N/A | None |
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE TAB 150MG |
1 |
Tier 1 |
25% | N/A | None |
DOXYCYCLINE MONO 100 MG CAP |
1 |
Tier 1 |
25% | N/A | None |
DOXYCYCLINE MONO 100 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
DOXYCYCLINE MONO 50 MG CAP |
1 |
Tier 1 |
25% | N/A | None |
DOXYCYCLINE MONOHYDRATE 75MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
DOXYCYCLINE TABLETS 150MG 30 BOT |
2 |
Tier 2 |
25% | N/A | None |
DRONABINOL CAPS 10MG |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
DRONABINOL CAPS 2.5MG |
2 |
Tier 2 |
25% | N/A | P Q:60 /30Days |
DRONABINOL CAPS 5MG |
2 |
Tier 2 |
25% | N/A | P Q:60 /30Days |
DROSPIRENONE-ETH ESTRADIOL TAB |
2 |
Tier 2 |
25% | N/A | None |
DROXIA 200MG CAPSULE |
3 |
Tier 3 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DROXIA 300MG CAPSULE |
3 |
Tier 3 |
25% | N/A | None |
DROXIA 400MG CAPSULE |
3 |
Tier 3 |
25% | N/A | None |
DUEXIS 26.6; 800mg/1; mg/1 |
4 |
Tier 4 |
25% | N/A | Q:90 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
25% | N/A | Q:90 /30Days |
DULOXETINE HCL DR 40 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
duramorph 0.5 mg/ml ampule |
1 |
Tier 1 |
25% | N/A | P |
duramorph 1 mg/ml ampule |
1 |
Tier 1 |
25% | N/A | P |
DUREZOL 0.05% EYE DROPS |
4 |
Tier 4 |
25% | N/A | Q:10 /25Days |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
2 |
Tier 2 |
25% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [JALYN] |
2 |
Tier 2 |
25% | N/A | Q:30 /30Days |