2018 Medicare Part D Plan Formulary Information |
IU Health Plans Medicare Select Plus (HMO) (H7220-009-1)
Benefit Details
|
The IU Health Plans Medicare Select Plus (HMO) (H7220-009-1) Formulary Drugs Starting with the Letter D in Knox County, IN: CMS MA Region 13 which includes: IN Plan Monthly Premium: $46.00 Deductible: $200 |
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 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:120 /30Days |
D-AMPHETAMINE ER 15 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:120 /30Days |
D-AMPHETAMINE ER 5 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:30 /30Days |
DACARBAZINE 200MG VIAL |
2* |
Generic |
$15.00 | N/A | None |
DACTINOMYCIN 0.5 MG VIAL [Cosmegen] |
5 |
Specialty Tier |
29% | N/A | None |
DALIRESP 250 MCG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
DALIRESP 500 MCG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
DALVANCE 500 MG VIAL |
5 |
Specialty Tier |
29% | N/A | None |
DANAZOL 100 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DANAZOL 50MG CAPSULE |
2* |
Generic |
$15.00 | 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* |
Generic |
$15.00 | N/A | None |
DANTROLENE SODIUM 100MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
DANTROLENE SODIUM 25MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
DANTROLENE SODIUM 50MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
DAPSONE 25 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
DAPSONE TABLETS 100MG 30 BLPK |
3 |
Preferred Brand |
$47.00 | N/A | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Preferred Brand |
$47.00 | N/A | None |
DAPTOMYCIN 500 MG VIAL [Cubicin] |
5 |
Specialty Tier |
29% | N/A | None |
DARAPRIM 25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DARZALEX 100 MG/5 ML VIAL |
5 |
Specialty Tier |
29% | N/A | None |
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEBLITANE 0.35 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
Decitabine 50 mg vial [Dacogen] |
5 |
Specialty Tier |
29% | N/A | None |
Delyla-28 tablet |
2* |
Generic |
$15.00 | N/A | None |
DELZICOL DR 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Specialty Tier |
29% | N/A | P |
DENAVIR 1% CREAM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DEPEN 250MG TITRATAB |
5 |
Specialty Tier |
29% | N/A | P |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DEPO-MEDROL 20MG/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:1 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESCOVY 200-25 MG TABLET |
5 |
Specialty Tier |
29% | N/A | None |
DESIPRAMINE 10 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DESIPRAMINE 25MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DESIPRAMINE 50MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DESIPRAMINE 75 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS |
2* |
Generic |
$15.00 | N/A | None |
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT |
2* |
Generic |
$15.00 | N/A | None |
DESLORATADINE 5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Desmopressin ac 4 mcg/ml vial |
2* |
Generic |
$15.00 | N/A | None |
DESMOPRESSIN ACETATE 0.1 MG TB |
2* |
Generic |
$15.00 | N/A | None |
DESMOPRESSIN ACETATE 0.2 MG TB |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
2* |
Generic |
$15.00 | N/A | None |
DESOGESTR-ETH ESTRA 0.15-0.03MG |
2* |
Generic |
$15.00 | N/A | None |
DESOGESTR-ETH ESTRAD |
2* |
Generic |
$15.00 | N/A | None |
Desonide 0.0005 MG/MG Topical Ointment |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DESONIDE 0.05% CREAM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DESONIDE 0.05% LOTION |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DESOXIMETASONE 0.25% CREAM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DESOXIMETASONE 0.25% OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DESVENLAFAXINE ER 100 MG TAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESVENLAFAXINE ER 50 MG TAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:240 /30Days |
Desvenlafaxine Succinate ER 100 mg [Pristiq] |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:120 /30Days |
Desvenlafaxine Succinate ER 25 mg tb [Pristiq] |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:480 /30Days |
Desvenlafaxine Succinate ER 50 mg tb [Pristiq] |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:240 /30Days |
DEXAMETHASONE 0.1% EYE DROP |
2* |
Generic |
$15.00 | N/A | None |
DEXAMETHASONE 0.5MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
2* |
Generic |
$15.00 | N/A | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2* |
Generic |
$15.00 | N/A | None |
DEXAMETHASONE 0.75MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
DEXAMETHASONE 1.5MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
Dexamethasone 10 MG/ML Injectable Solution |
2* |
Generic |
$15.00 | 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 |
$6.00 | N/A | None |
DEXAMETHASONE 2MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
DEXAMETHASONE 4MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
DEXAMETHASONE 6MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD |
2* |
Generic |
$15.00 | N/A | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:30 /30Days |
DEXILANT DR 60 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | S Q:30 /30Days |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
2* |
Generic |
$15.00 | N/A | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
2* |
Generic |
$15.00 | N/A | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
2* |
Generic |
$15.00 | N/A | Q:60 /30Days |
Dexrazoxane 500 MG Vial |
5 |
Specialty Tier |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 10 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:30 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:60 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:60 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:60 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:30 /30Days |
DEXTROAMP-AMPHETAMIN 20 MG TAB |
2* |
Generic |
$15.00 | N/A | Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 30 MG TAB |
2* |
Generic |
$15.00 | N/A | Q:60 /30Days |
DEXTROAMPHETAMINE 10 MG TAB |
2* |
Generic |
$15.00 | N/A | Q:180 /30Days |
DEXTROAMPHETAMINE 5 MG TAB |
2* |
Generic |
$15.00 | N/A | Q:180 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2* |
Generic |
$15.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 10%-1/4NS IV TUBEX |
2* |
Generic |
$15.00 | N/A | None |
Dextrose 10%-water iv solution |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE 5%-0.45% NACL IV SOLN |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE 5%-0.9% NACL IV SOLN |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
2* |
Generic |
$15.00 | N/A | None |
Dextrose 5%-lr iv solution |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE 5%-WATER IV SOLN |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
2* |
Generic |
$15.00 | N/A | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIASTAT ACUDIAL 5-7.5-10 MG KT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIAZEPAM 10 MG TABLET [Valium] |
2* |
Generic |
$15.00 | N/A | Q:120 /30Days |
DIAZEPAM 2 MG TABLET [Valium] |
2* |
Generic |
$15.00 | N/A | Q:600 /30Days |
DIAZEPAM 5 MG TABLET [Valium] |
2* |
Generic |
$15.00 | N/A | Q:240 /30Days |
DIAZEPAM 5 MG/5 ML SOLUTION |
2* |
Generic |
$15.00 | N/A | Q:1200 /30Days |
DIAZEPAM 5 MG/ML ORAL CONC |
2* |
Generic |
$15.00 | N/A | Q:240 /30Days |
DICLOFENAC 0.1% EYE DROPS |
2* |
Generic |
$15.00 | N/A | None |
DICLOFENAC POT 50 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DICLOFENAC SOD EC 25 MG TAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SOD EC 50 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DICLOFENAC SOD EC 75 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DICLOFENAC SOD ER 100 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
Diclofenac Sodium 1% gel |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:1000 /30Days |
DICLOXACILLIN 250MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DICLOXACILLIN SODIUM 500MG CAP |
2* |
Generic |
$15.00 | N/A | None |
DICYCLOMINE 10 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DICYCLOMINE 20 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
2* |
Generic |
$15.00 | N/A | None |
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC] |
2* |
Generic |
$15.00 | N/A | None |
DIDANOSINE DR 250 MG CAPSULE [Videx EC] |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIDANOSINE DR 400 MG CAPSULE [Videx EC] |
2* |
Generic |
$15.00 | N/A | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
29% | N/A | S Q:20 /10Days |
DIFLORASONE 0.05% CREAM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIFLORASONE 0.05% OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIFLUNISAL 500 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIGITEK 125 MCG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DIGITEK 250 MCG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DIGOX 125 MCG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DIGOX 250 MCG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
2* |
Generic |
$15.00 | N/A | None |
DIGOXIN 125 MCG TABLET [Lanoxin] |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGOXIN 250 MCG TABLET [Lanoxin] |
2* |
Generic |
$15.00 | N/A | None |
DIGOXIN 500 MCG/2 ML AMPULE [Lanoxin] |
2* |
Generic |
$15.00 | N/A | None |
DIHYDROERGOTAMINE 1 MG/ML AM |
3 |
Preferred Brand |
$47.00 | N/A | None |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
5 |
Specialty Tier |
29% | N/A | None |
DILANTIN CAPSULES 30 MG ER |
3 |
Preferred Brand |
$47.00 | N/A | None |
DILT XR 120 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DILT XR 180 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DILT XR 240 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
1* |
Preferred Generic |
$6.00 | N/A | None |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR] |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 24HR ER 360 MG CAP [Tiazac] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DILTIAZEM 24HR ER 420 MG CAP [Tiazac] |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 25 MG/5 ML VIAL |
2* |
Generic |
$15.00 | N/A | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
1* |
Preferred Generic |
$6.00 | N/A | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
1* |
Preferred Generic |
$6.00 | N/A | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
1* |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM HCL 100MG VIAL |
2* |
Generic |
$15.00 | N/A | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Preferred Brand |
$47.00 | N/A | None |
diphenhydramine 50 mg/ml vial |
2* |
Generic |
$15.00 | N/A | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
2* |
Generic |
$15.00 | N/A | None |
DIPHENOXYLATE/ATROPINE LIQ |
2* |
Generic |
$15.00 | N/A | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Preferred Brand |
$47.00 | N/A | None |
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus |
3 |
Preferred Brand |
$47.00 | N/A | None |
DIPYRIDAMOLE 25 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
DIPYRIDAMOLE 50 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
DIPYRIDAMOLE 75 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DISOPYRAMIDE 100 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
2* |
Generic |
$15.00 | N/A | None |
DISULFIRAM 250 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DISULFIRAM 500 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DIVALPROEX DR 125 MG CAP SPRNK |
2* |
Generic |
$15.00 | N/A | None |
DIVALPROEX SOD DR 125 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DIVALPROEX SOD DR 250 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DIVALPROEX SOD DR 500 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DIVALPROEX SOD ER 500 MG TAB |
3 |
Preferred Brand |
$47.00 | N/A | None |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVIGEL 1 MG GEL PACKET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DOCETAXEL 160 MG/16 ML VIAL |
5 |
Specialty Tier |
29% | N/A | None |
Docetaxel 80 mg/4 ml vial |
5 |
Specialty Tier |
29% | N/A | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
3 |
Preferred Brand |
$47.00 | N/A | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
3 |
Preferred Brand |
$47.00 | N/A | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
3 |
Preferred Brand |
$47.00 | N/A | None |
DONEPEZIL HCL 10 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DONEPEZIL HCL 5 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DONEPEZIL HCL ODT 10 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DONEPEZIL HCL ODT 5 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DORIPENEM 500 MG VIAL [Doribax] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
2* |
Generic |
$15.00 | N/A | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2* |
Generic |
$15.00 | N/A | None |
DOXAZOSIN MESYLATE 1 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DOXAZOSIN MESYLATE 2 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DOXAZOSIN MESYLATE 4 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DOXAZOSIN MESYLATE 8 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DOXEPIN 10 MG/ML ORAL CONC |
2* |
Generic |
$15.00 | N/A | P |
DOXEPIN 10MG CAPSULE |
2* |
Generic |
$15.00 | N/A | P |
DOXEPIN 50 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | P |
DOXEPIN 75MG CAPSULE |
2* |
Generic |
$15.00 | N/A | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
2* |
Generic |
$15.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$15.00 | N/A | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
2* |
Generic |
$15.00 | N/A | P |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Doxercalciferol 1 mcg capsule [HECTOROL] |
5 |
Specialty Tier |
29% | N/A | None |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Doxercalciferol 4 mcg/2 ml amp [HECTOROL] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE |
2* |
Generic |
$15.00 | N/A | None |
Doxorubicin liposome 20mg/10ml |
5 |
Specialty Tier |
29% | N/A | None |
DOXY 100 VIAL |
2* |
Generic |
$15.00 | N/A | None |
doxycycline 25 mg/5 ml susp |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DOXYCYCLINE HYCLATE 100 MG CAP |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE 100 MG TAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2* |
Generic |
$15.00 | N/A | None |
DOXYCYCLINE HYCLATE 50 MG CAP |
3 |
Preferred Brand |
$47.00 | N/A | None |
DOXYCYCLINE MONO 100 MG CAP |
2* |
Generic |
$15.00 | N/A | None |
DOXYCYCLINE MONO 100 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DOXYCYCLINE MONO 150 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DOXYCYCLINE MONO 50 MG CAP |
2* |
Generic |
$15.00 | N/A | None |
DOXYCYCLINE MONO 50 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DOXYCYCLINE MONO 75 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
DRONABINOL CAPS 10MG |
5 |
Specialty Tier |
29% | N/A | P |
DRONABINOL CAPS 2.5MG |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL CAPS 5MG |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
DROSPIRENONE-EE 3-0.02 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DROSPIRENONE-EE 3-0.03 MG TAB |
2* |
Generic |
$15.00 | N/A | None |
DUAVEE 0.45-20 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
DULOXETINE HCL DR 20 MG CAP [Cymbalta] |
2* |
Generic |
$15.00 | N/A | Q:180 /30Days |
DULOXETINE HCL DR 30 MG CAP [Cymbalta] |
2* |
Generic |
$15.00 | N/A | Q:120 /30Days |
DULOXETINE HCL DR 40 MG CAPSULE [Cymbalta] |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:90 /30Days |
DULOXETINE HCL DR 60 MG CAP [Cymbalta] |
2* |
Generic |
$15.00 | N/A | Q:60 /30Days |
DUOPA 4.63 MG-20 MG/ML SUSPENSION |
5 |
Specialty Tier |
29% | N/A | P |
duramorph 0.5 mg/ml ampule |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:4000 /30Days |
duramorph 1 mg/ml ampule |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:2000 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DUREZOL 0.05% EYE DROPS |
3 |
Preferred Brand |
$47.00 | N/A | None |
DUTASTERIDE 0.5 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Dysport 3001/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | P Q:3 /84Days |
DYSPORT 500 UNITS VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | P Q:3 /84Days |