Q1Medicare.com 2017 Medicare Part D or Medicare Advantage Plan Formulary Browser

2017 Medicare Part D Plan Formulary Information
Optimum Emerald Full (HMO SNP) (H5594-017-0) Benefit Details
The Optimum Emerald Full (HMO SNP) (H5594-017-0) Formulary Drugs Starting with the Letter D in Pasco County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $29.10 Deductible: $400
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
D-AMPHETAMINE ER 10 MG CAPSULE	2	Preferred Brand	$45.00	N/A	Q:90 /30Days
D-AMPHETAMINE ER 15 MG CAPSULE	2	Preferred Brand	$45.00	N/A	Q:120 /30Days
D-AMPHETAMINE ER 5 MG CAPSULE	2	Preferred Brand	$45.00	N/A	Q:90 /30Days
DACARBAZINE 200MG VIAL	3	Non-Preferred Drug	$95.00	N/A	P
DAKLINZA 30 MG TABLET	4	Specialty Tier	25%	N/A	P
DAKLINZA 60 MG TABLET	4	Specialty Tier	25%	N/A	P
DAKLINZA 90 MG TABLET	4	Specialty Tier	25%	N/A	P
DALIRESP 500 MCG TABLET	2	Preferred Brand	$45.00	N/A	P Q:30 /30Days
DANAZOL 100MG CAPSULE	2	Preferred Brand	$45.00	N/A	None
DANAZOL 50MG CAPSULE	2	Preferred Brand	$45.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DANAZOL CAPSULES USP 200MG (100 CT)	2	Preferred Brand	$45.00	N/A	None
DANTROLENE SODIUM 100MG CAPSULE	2	Preferred Brand	$45.00	N/A	None
DANTROLENE SODIUM 25MG CAPSULE	2	Preferred Brand	$45.00	N/A	None
DANTROLENE SODIUM 50MG CAPSULE	2	Preferred Brand	$45.00	N/A	None
DAPSONE TABLETS 100MG 30 BLPK	2	Preferred Brand	$45.00	N/A	None
DAPSONE TABLETS 25MG 30 BLPK	2	Preferred Brand	$45.00	N/A	None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML	2	Preferred Brand	$45.00	N/A	None
DAPTOMYCIN 500 MG VIAL [Cubicin]	4	Specialty Tier	25%	N/A	P
DARAPRIM 25 MG TABLET	4	Specialty Tier	25%	N/A	P
DARIFENACIN ER 15 MG TABLET [Enablex]	3	Non-Preferred Drug	$95.00	N/A	None
DARIFENACIN ER 7.5 MG TABLET [Enablex]	3	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DARZALEX 100 MG/5 ML VIAL	4	Specialty Tier	25%	N/A	P
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL	1*	Preferred Generic	$0.00	N/A	P
Decitabine 50 mg vial [Dacogen]	4	Specialty Tier	25%	N/A	P
DELZICOL DR 400 MG CAPSULE	3	Non-Preferred Drug	$95.00	N/A	None
DEMECLOCYCLINE HCL 150MG TABLET	3	Non-Preferred Drug	$95.00	N/A	None
DEMECLOCYCLINE HCL 300MG TABLET	3	Non-Preferred Drug	$95.00	N/A	None
DEMSER CAPSULES 250MG (100 CT)	4	Specialty Tier	25%	N/A	None
DENAVIR 1% CREAM	4	Specialty Tier	25%	N/A	None
DEPEN 250MG TITRATAB	4	Specialty Tier	25%	N/A	None
DEPO-ESTRADIOL 5MG/ML VIAL	3	Non-Preferred Drug	$95.00	N/A	P
DEPO-MEDROL 20MG/ML VIAL	3	Non-Preferred Drug	$95.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE	3	Non-Preferred Drug	$95.00	N/A	Q:1 /90Days
DESCOVY 200-25 MG TABLET	4	Specialty Tier	25%	N/A	Q:30 /30Days
DESIPRAMINE 10 MG TABLET	2	Preferred Brand	$45.00	N/A	None
DESIPRAMINE 25MG TABLET	2	Preferred Brand	$45.00	N/A	None
DESIPRAMINE 50MG TABLET	2	Preferred Brand	$45.00	N/A	None
DESIPRAMINE 75 MG TABLET	2	Preferred Brand	$45.00	N/A	None
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS	2	Preferred Brand	$45.00	N/A	None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT	2	Preferred Brand	$45.00	N/A	None
DESLORATADINE 2.5 MG ODDT	2	Preferred Brand	$45.00	N/A	S Q:30 /30Days
DESLORATADINE 5 MG ODDT	2	Preferred Brand	$45.00	N/A	S Q:30 /30Days
DESLORATADINE 5 MG TABLET	2	Preferred Brand	$45.00	N/A	S Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Desmopressin ac 4 mcg/ml vial	2	Preferred Brand	$45.00	N/A	None
Desmopressin acetate 0.1 mg tb	2	Preferred Brand	$45.00	N/A	None
Desmopressin Acetate 0.1mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL	2	Preferred Brand	$45.00	N/A	None
Desmopressin acetate 0.2 mg tb	2	Preferred Brand	$45.00	N/A	None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR	2	Preferred Brand	$45.00	N/A	None
DESONIDE 0.05% CREAM	2	Preferred Brand	$45.00	N/A	None
DESONIDE 0.05% OINTMENT	2	Preferred Brand	$45.00	N/A	None
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC	2	Preferred Brand	$45.00	N/A	None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Preferred Brand	$45.00	N/A	None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Preferred Brand	$45.00	N/A	None
Desoximetasone 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Preferred Brand	$45.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DESOXYN 5 MG TABLET	4	Specialty Tier	25%	N/A	P Q:150 /30Days
DESVENLAFAXINE ER 100 MG TAB	3	Non-Preferred Drug	$95.00	N/A	Q:30 /30Days
DESVENLAFAXINE ER 50 MG TAB	3	Non-Preferred Drug	$95.00	N/A	Q:30 /30Days
Desvenlafaxine Succinate ER 100 mg [Pristiq]	3	Non-Preferred Drug	$95.00	N/A	Q:30 /30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]	3	Non-Preferred Drug	$95.00	N/A	Q:30 /30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]	3	Non-Preferred Drug	$95.00	N/A	Q:30 /30Days
DEXAMETHASONE 0.1% EYE DROP	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 0.5MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 0.5MG/5ML ELX	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 0.75MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 1.5MG TABLET	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXAMETHASONE 1MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 2MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 4MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE 6MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD	1*	Preferred Generic	$0.00	N/A	P
DEXMETHYLPHENIDATE HCL 10MG TABLET	2	Preferred Brand	$45.00	N/A	Q:120 /30Days
DEXMETHYLPHENIDATE HCL 2.5MG TABLET	2	Preferred Brand	$45.00	N/A	Q:90 /30Days
DEXMETHYLPHENIDATE HCL 5MG TABLET	2	Preferred Brand	$45.00	N/A	Q:90 /30Days
Dexrazoxane 500 MG Vial	1*	Preferred Generic	$0.00	N/A	P
DEXTROAMP-AMPHET ER 10 MG CAP	3	Non-Preferred Drug	$95.00	N/A	Q:60 /30Days
DEXTROAMP-AMPHET ER 15 MG CAP	3	Non-Preferred Drug	$95.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXTROAMP-AMPHET ER 20 MG CAP	3	Non-Preferred Drug	$95.00	N/A	Q:60 /30Days
DEXTROAMP-AMPHET ER 25 MG CAP	3	Non-Preferred Drug	$95.00	N/A	Q:60 /30Days
DEXTROAMP-AMPHET ER 30 MG CAP	3	Non-Preferred Drug	$95.00	N/A	Q:60 /30Days
DEXTROAMP-AMPHET ER 5 MG CAP	3	Non-Preferred Drug	$95.00	N/A	Q:60 /30Days
DEXTROAMP-AMPHETAMIN 20 MG TAB	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
DEXTROAMP-AMPHETAMIN 30 MG TAB	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
DEXTROAMPHETAMINE 10MG TABLET	1*	Preferred Generic	$0.00	N/A	Q:180 /30Days
DEXTROAMPHETAMINE 5MG TABLET	1*	Preferred Generic	$0.00	N/A	Q:90 /30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
DEXTROSE 10%-1/4NS IV TUBEX	1*	Preferred Generic	$0.00	N/A	None
Dextrose 10%-water iv solution	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXTROSE 2.5%-1/2NS IV SOLUTION	1*	Preferred Generic	$0.00	N/A	None
DEXTROSE 5%-1/4NS IV SOLUTION	2	Preferred Brand	$45.00	N/A	None
Dextrose 5%-lr iv solution	1*	Preferred Generic	$0.00	N/A	None
Dextrose 5%-ns iv solution	1*	Preferred Generic	$0.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	2	Preferred Brand	$45.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	1*	Preferred Generic	$0.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE	1*	Preferred Generic	$0.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG	1*	Preferred Generic	$0.00	N/A	None
DEXTROSE INJECTION USP 5 4 X 100ML CTR	2	Preferred Brand	$45.00	N/A	None
DIASTAT 2.5 MG PEDI SYSTEM	3	Non-Preferred Drug	$95.00	N/A	None
DIASTAT ACUDIAL 12.5-15-20 MG	3	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIASTAT ACUDIAL 5-7.5-10 MG KT	3	Non-Preferred Drug	$95.00	N/A	None
DIAZEPAM 10 MG TABLET	1*	Preferred Generic	$0.00	N/A	Q:120 /30Days
Diazepam 2mg/1 100 TABLET BOTTLE	1*	Preferred Generic	$0.00	N/A	None
Diazepam 5mg/1 100 TABLET BOTTLE	1*	Preferred Generic	$0.00	N/A	None
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC	1*	Preferred Generic	$0.00	N/A	None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)	1*	Preferred Generic	$0.00	N/A	None
DICLOFENAC SODIUM 0.1% DROPS	1*	Preferred Generic	$0.00	N/A	None
Diclofenac sodium 1.5% soln	2	Preferred Brand	$45.00	N/A	P
Diclofenac Sodium 1% gel	3	Non-Preferred Drug	$95.00	N/A	P
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	1*	Preferred Generic	$0.00	N/A	None
Diclofenac Sodium 3% gel	4	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)	1*	Preferred Generic	$0.00	N/A	None
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE	1*	Preferred Generic	$0.00	N/A	None
DICLOXACILLIN 250MG CAPSULE	1*	Preferred Generic	$0.00	N/A	None
DICLOXACILLIN SODIUM 500MG CAP	1*	Preferred Generic	$0.00	N/A	None
DICYCLOMINE 10MG CAPSULE	1*	Preferred Generic	$0.00	N/A	None
DICYCLOMINE HCL 20MG TABLET (500 CT)	1*	Preferred Generic	$0.00	N/A	None
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE	2	Preferred Brand	$45.00	N/A	None
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE	2	Preferred Brand	$45.00	N/A	None
DIDANOSINE 400MG CAPSULE DELAYED RELEASE	2	Preferred Brand	$45.00	N/A	None
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT	2	Preferred Brand	$45.00	N/A	None
DIFLORASONE 0.05% CREAM	2	Preferred Brand	$45.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIFLORASONE 0.05% OINTMENT	2	Preferred Brand	$45.00	N/A	None
DIFLUNISAL 500MG TABLET	2	Preferred Brand	$45.00	N/A	None
Digitek 125 mcg tablet	2	Preferred Brand	$45.00	N/A	Q:45 /30Days
Digitek 250 mcg tablet	2	Preferred Brand	$45.00	N/A	P
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER	2	Preferred Brand	$45.00	N/A	None
Digoxin 125ug 100 TABLET BOTTLE	2	Preferred Brand	$45.00	N/A	Q:45 /30Days
Digoxin 250ug 100 TABLET BOTTLE	2	Preferred Brand	$45.00	N/A	P
DIHYDROERGOTAMINE 1 MG/ML AM	3	Non-Preferred Drug	$95.00	N/A	None
DIHYDROERGOTAMINE 4 MG/ML SPRAY	3	Non-Preferred Drug	$95.00	N/A	None
DILANTIN CAPSULES 30 MG ER	2	Preferred Brand	$45.00	N/A	None
DILT XR 120 MG CAPSULE	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
DILTIAZEM 24HR ER 120 MG CAP	1*	Preferred Generic	$0.00	N/A	Q:30 /30Days
DILTIAZEM 24HR ER 240 MG CAP	1*	Preferred Generic	$0.00	N/A	Q:30 /30Days
DILTIAZEM 25 MG/5 ML VIAL	1*	Preferred Generic	$0.00	N/A	P
DILTIAZEM 30 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DILTIAZEM 90 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DILTIAZEM ER 240MG CAPSULE SA	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
DILTIAZEM HCL 120MG ER CAPSULE	1*	Preferred Generic	$0.00	N/A	None
DILTIAZEM HCL 120MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DILTIAZEM HCL 180 MG ER 500 CAPSULE BOTTLE	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
DILTIAZEM HCL 300 MG ER 90 CAPSULE BOTTLE	1*	Preferred Generic	$0.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DILTIAZEM HCL 360 MG ER CAPSULES	1*	Preferred Generic	$0.00	N/A	Q:30 /30Days
DILTIAZEM HCL 60 MG ER CAPSULE	1*	Preferred Generic	$0.00	N/A	None
DILTIAZEM HCL 60 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DILTIAZEM HCL 90 MG ER CAPSULES 100 CAPSULE BOTTLE	1*	Preferred Generic	$0.00	N/A	None
Diltiazem hcl er 420 mg cap	1*	Preferred Generic	$0.00	N/A	Q:30 /30Days
DIPENTUM 250 MG CAPSULE	2	Preferred Brand	$45.00	N/A	None
diphenhydramine 50 mg/ml vial	1*	Preferred Generic	$0.00	N/A	None
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE	1*	Preferred Generic	$0.00	N/A	None
DIPHENOXYLATE/ATROPINE LIQ	1*	Preferred Generic	$0.00	N/A	None
DIPHTHERIA-TETANUS TOXOIDS-PED	1*	Preferred Generic	$0.00	N/A	None
DISOPYRAMIDE 100 MG CAPSULE	2	Preferred Brand	$45.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)	2	Preferred Brand	$45.00	N/A	P
Disulfiram 250mg/1	1*	Preferred Generic	$0.00	N/A	None
Disulfiram 500mg/1	1*	Preferred Generic	$0.00	N/A	None
DIVALPROEX SODIUM 125 MG CAP	2	Preferred Brand	$45.00	N/A	None
DIVALPROEX SODIUM 125MG TBEC	2	Preferred Brand	$45.00	N/A	None
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Preferred Brand	$45.00	N/A	None
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Preferred Brand	$45.00	N/A	None
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT	2	Preferred Brand	$45.00	N/A	None
DIVALPROEX SODIUM TABLETS ER 500MG 100 BOT	2	Preferred Brand	$45.00	N/A	None
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 8 mL in 1 VIAL, MULTI-DOSE	4	Specialty Tier	25%	N/A	P
Docetaxel 80 mg/4 ml vial	4	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DONEPEZIL HCL 10 MG TABLET	2	Preferred Brand	$45.00	N/A	Q:30 /30Days
DONEPEZIL HCL 5 MG TABLET	2	Preferred Brand	$45.00	N/A	Q:30 /30Days
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Preferred Brand	$45.00	N/A	Q:30 /30Days
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Preferred Brand	$45.00	N/A	Q:30 /30Days
DORIBAX 500 MG VIAL	3	Non-Preferred Drug	$95.00	N/A	P
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR	2	Preferred Brand	$45.00	N/A	None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL	2	Preferred Brand	$45.00	N/A	None
Doxazosin 2mg 100 TABLET BOTTLE	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
DOXAZOSIN MESYLATE 4MG TABLET	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
DOXAZOSIN MESYLATE TABLETS 8 MG	1*	Preferred Generic	$0.00	N/A	Q:60 /30Days
DOXAZOSIN TABLET 1MG (100 CT)	1*	Preferred Generic	$0.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DOXEPIN 10 MG/ML ORAL CONC	2	Preferred Brand	$45.00	N/A	P
DOXEPIN 10MG CAPSULE	2	Preferred Brand	$45.00	N/A	P
DOXEPIN 75MG CAPSULE	2	Preferred Brand	$45.00	N/A	P
DOXEPIN HCL 25MG CAPSULE (100 CT)	2	Preferred Brand	$45.00	N/A	P
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE	2	Preferred Brand	$45.00	N/A	P
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK	2	Preferred Brand	$45.00	N/A	P
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT	2	Preferred Brand	$45.00	N/A	P
Doxercalciferol 0.5 mcg capsule [HECTOROL]	3	Non-Preferred Drug	$95.00	N/A	None
Doxercalciferol 1 mcg capsule [HECTOROL]	4	Specialty Tier	25%	N/A	None
Doxercalciferol 2.5 mcg capsule [HECTOROL]	4	Specialty Tier	25%	N/A	None
Doxercalciferol 4 mcg/2 ml amp [HECTOROL]	3	Non-Preferred Drug	$95.00	N/A	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	1*	Preferred Generic	$0.00	N/A	P
Doxorubicin liposome 20mg/10ml	4	Specialty Tier	25%	N/A	P
DOXYCYCLINE 50MG TABLET (100 CT)	1*	Preferred Generic	$0.00	N/A	None
Doxycycline 75mg/1	1*	Preferred Generic	$0.00	N/A	None
DOXYCYCLINE MONO 100 MG CAP	1*	Preferred Generic	$0.00	N/A	None
DOXYCYCLINE MONO 100 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DOXYCYCLINE MONO 50 MG CAP	1*	Preferred Generic	$0.00	N/A	None
DOXYCYCLINE MONOHYDRATE 75MG TABLET	1*	Preferred Generic	$0.00	N/A	None
DRONABINOL CAPS 10MG	3	Non-Preferred Drug	$95.00	N/A	P
DRONABINOL CAPS 2.5MG	3	Non-Preferred Drug	$95.00	N/A	P Q:62 /30Days
DRONABINOL CAPS 5MG	3	Non-Preferred Drug	$95.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DUAVEE 0.45-20 MG TABLET	3	Non-Preferred Drug	$95.00	N/A	None
DULERA INHALATION AEROSOL	2	Preferred Brand	$45.00	N/A	Q:13 /30Days
DULERA INHALATION AEROSOL	2	Preferred Brand	$45.00	N/A	Q:13 /30Days
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta]	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta]	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
DULOXETINE HCL DR 40 MG CAPSULE [Cymbalta]	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta]	2	Preferred Brand	$45.00	N/A	Q:60 /30Days
duramorph 0.5 mg/ml ampule	3	Non-Preferred Drug	$95.00	N/A	P
duramorph 1 mg/ml ampule	3	Non-Preferred Drug	$95.00	N/A	P
DUREZOL 0.05% EYE DROPS	3	Non-Preferred Drug	$95.00	N/A	None
DUTASTERIDE 0.5 MG CAPSULE [Avodart]	2	Preferred Brand	$45.00	N/A	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	Preferred Brand	$45.00	N/A	Q:30 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Optimum Emerald Full (HMO SNP) 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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

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.