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HealthPartners Freedom Ultimate with Enhanced Rx (Cost) (H2462-012-0)
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2018 Medicare Part D Plan Formulary Information
HealthPartners Freedom Ultimate with Enhanced Rx (Cost) (H2462-012-0)
Benefit Details           
The HealthPartners Freedom Ultimate with Enhanced Rx (Cost) (H2462-012-0)
Formulary Drugs Starting with the Letter D
in Pipestone County, MN: CMS MA Region 19 which includes: MN
Plan Monthly Premium: $375.90 Deductible: $115
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 Drug 50%50%Q:6
/1Days
D-AMPHETAMINE ER 15 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:4
/1Days
D-AMPHETAMINE ER 5 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:6
/1Days
DACARBAZINE 200MG VIAL   4 Non-Preferred Drug 50%50%P
DACTINOMYCIN 0.5 MG VIAL [Cosmegen]   5 Specialty Tier 29%N/AP
DAKLINZA 30 MG TABLET   5 Specialty Tier 29%N/AP
DAKLINZA 60 MG TABLET   5 Specialty Tier 29%N/AP
DAKLINZA 90 MG TABLET   5 Specialty Tier 29%N/AP
DALIRESP 250 MCG TABLET   3 Preferred Brand $47.00$94.00P
DALIRESP 500 MCG TABLET   3 Preferred Brand $47.00$94.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DANAZOL 100 MG CAPSULE   4 Non-Preferred Drug 50%50%None
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 50%50%None
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 50%50%None
DANTROLENE SODIUM 100MG CAPSULE   4 Non-Preferred Drug 50%50%None
DANTROLENE SODIUM 25MG CAPSULE   4 Non-Preferred Drug 50%50%None
DANTROLENE SODIUM 50MG CAPSULE   4 Non-Preferred Drug 50%50%None
DAPSONE 25 MG TABLET   2 Generic $14.00$28.00None
DAPSONE TABLETS 100MG 30 BLPK   2 Generic $14.00$28.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand $47.00$94.00None
DAPTOMYCIN 500 MG VIAL [Cubicin]   5 Specialty Tier 29%N/AP
DARAPRIM 25 MG TABLET   3 Preferred Brand $47.00$94.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DARZALEX 100 MG/5 ML VIAL   5 Specialty Tier 29%N/AP
daunorubicin hydrochloride 5mg/mL 10 VIAL per CARTON / 4 mL in 1 VIAL   4 Non-Preferred Drug 50%50%P
DEBLITANE 0.35 MG TABLET   2 Generic $14.00$28.00None
Decitabine 50 mg vial [Dacogen]   5 Specialty Tier 29%N/AP
Delyla-28 tablet   2 Generic $14.00$28.00None
DELZICOL DR 400 MG CAPSULE   3 Preferred Brand $47.00$94.00None
DEMECLOCYCLINE 150 MG TABLET   4 Non-Preferred Drug 50%50%None
DEMECLOCYCLINE 300 MG TABLET   4 Non-Preferred Drug 50%50%None
DEMSER CAPSULES 250MG (100 CT)   5 Specialty Tier 29%N/AP
DEPEN 250MG TITRATAB   5 Specialty Tier 29%N/ANone
DEPO-PROVERA 400MG/ML VIAL   4 Non-Preferred Drug 50%50%P
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/ANone
DESIPRAMINE 10 MG TABLET   4 Non-Preferred Drug 50%50%None
DESIPRAMINE 25MG TABLET   4 Non-Preferred Drug 50%50%None
DESIPRAMINE 50MG TABLET   4 Non-Preferred Drug 50%50%None
DESIPRAMINE 75 MG TABLET   4 Non-Preferred Drug 50%50%None
DESIPRAMINE HYDROCHLORIDE 150 MG TABLETS   4 Non-Preferred Drug 50%50%None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT   4 Non-Preferred Drug 50%50%None
Desmopressin ac 4 mcg/ml vial   4 Non-Preferred Drug 50%50%None
DESMOPRESSIN ACETATE 0.1 MG TB   4 Non-Preferred Drug 50%50%None
DESMOPRESSIN ACETATE 0.2 MG TB   4 Non-Preferred Drug 50%50%None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DESOGESTR-ETH ESTRA 0.15-0.03MG   2 Generic $14.00$28.00None
DESOGESTR-ETH ESTRAD   2 Generic $14.00$28.00None
Desonide 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 50%50%None
DESONIDE 0.05% CREAM   4 Non-Preferred Drug 50%50%None
DESONIDE 0.05% LOTION   4 Non-Preferred Drug 50%50%None
Desoximetasone 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 50%50%None
DESOXIMETASONE 0.25% CREAM   4 Non-Preferred Drug 50%50%None
DESOXIMETASONE 0.25% OINTMENT   4 Non-Preferred Drug 50%50%None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 50%50%None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 50%50%None
Desvenlafaxine Succinate ER 100 mg [Pristiq]   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   4 Non-Preferred Drug 50%50%P
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   4 Non-Preferred Drug 50%50%P
DEXAMETHASONE 0.1% EYE DROP   3 Preferred Brand $47.00$94.00None
DEXAMETHASONE 0.5MG TABLET   1 Preferred Generic $5.00$10.00P
DEXAMETHASONE 0.5MG/0.5ML DROP   3 Preferred Brand $47.00$94.00None
DEXAMETHASONE 0.5MG/5ML ELX   3 Preferred Brand $47.00$94.00P
DEXAMETHASONE 0.75MG TABLET   1 Preferred Generic $5.00$10.00P
DEXAMETHASONE 1.5MG TABLET   1 Preferred Generic $5.00$10.00P
DEXAMETHASONE 1MG TABLET   1 Preferred Generic $5.00$10.00P
DEXAMETHASONE 2MG TABLET   1 Preferred Generic $5.00$10.00P
DEXAMETHASONE 4MG TABLET   1 Preferred Generic $5.00$10.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXAMETHASONE 6MG TABLET   1 Preferred Generic $5.00$10.00P
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD   4 Non-Preferred Drug 50%50%P
DEXMETHYLPHENIDATE ER 10 MG CAP   4 Non-Preferred Drug 50%50%Q:3
/1Days
DEXMETHYLPHENIDATE ER 15 MG CP   4 Non-Preferred Drug 50%50%Q:2
/1Days
Dexmethylphenidate er 20 mg cp   4 Non-Preferred Drug 50%50%Q:2
/1Days
Dexmethylphenidate er 25 mg cp   4 Non-Preferred Drug 50%50%Q:1
/1Days
DEXMETHYLPHENIDATE ER 30 MG CP   4 Non-Preferred Drug 50%50%Q:1
/1Days
Dexmethylphenidate er 35 mg cp   4 Non-Preferred Drug 50%50%Q:1
/1Days
DEXMETHYLPHENIDATE ER 40 MG CP   4 Non-Preferred Drug 50%50%Q:1
/1Days
DEXMETHYLPHENIDATE ER 5 MG CAP   4 Non-Preferred Drug 50%50%Q:3
/1Days
DEXMETHYLPHENIDATE HCL 10MG TABLET   3 Preferred Brand $47.00$94.00Q:2
/1Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   3 Preferred Brand $47.00$94.00Q:6
/1Days
DEXMETHYLPHENIDATE HCL 5MG TABLET   3 Preferred Brand $47.00$94.00Q:4
/1Days
Dexrazoxane 500 MG Vial   4 Non-Preferred Drug 50%50%P
DEXTROAMP-AMPHET ER 10 MG CAP   4 Non-Preferred Drug 50%50%Q:3
/1Days
DEXTROAMP-AMPHET ER 15 MG CAP   4 Non-Preferred Drug 50%50%Q:3
/1Days
DEXTROAMP-AMPHET ER 20 MG CAP   4 Non-Preferred Drug 50%50%Q:3
/1Days
DEXTROAMP-AMPHET ER 25 MG CAP   4 Non-Preferred Drug 50%50%Q:2
/1Days
DEXTROAMP-AMPHET ER 30 MG CAP   4 Non-Preferred Drug 50%50%Q:2
/1Days
DEXTROAMP-AMPHET ER 5 MG CAP   4 Non-Preferred Drug 50%50%Q:3
/1Days
DEXTROAMP-AMPHETAMIN 20 MG TAB   3 Preferred Brand $47.00$94.00Q:3
/1Days
DEXTROAMP-AMPHETAMIN 30 MG TAB   3 Preferred Brand $47.00$94.00Q:2
/1Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXTROAMPHETAMINE 10 MG TAB   4 Non-Preferred Drug 50%50%Q:6
/1Days
DEXTROAMPHETAMINE 5 MG TAB   4 Non-Preferred Drug 50%50%Q:6
/1Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   3 Preferred Brand $47.00$94.00Q:6
/1Days
Dextrose 10%-water iv solution   4 Non-Preferred Drug 50%50%None
DEXTROSE 2.5%-1/2NS IV SOLUTION   4 Non-Preferred Drug 50%50%None
DEXTROSE 5%-0.45% NACL IV SOLN   4 Non-Preferred Drug 50%50%None
DEXTROSE 5%-0.9% NACL IV SOLN   4 Non-Preferred Drug 50%50%None
Dextrose 5%-lr iv solution   4 Non-Preferred Drug 50%50%None
DEXTROSE 5%-WATER IV SOLN   4 Non-Preferred Drug 50%50%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Drug 50%50%None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 50%50%Q:40
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 50%50%Q:40
/30Days
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Drug 50%50%Q:20
/30Days
DIAZEPAM 10 MG TABLET [Valium]   1 Preferred Generic $5.00$10.00Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   1 Preferred Generic $5.00$10.00Q:180
/30Days
DIAZEPAM 5 MG TABLET [Valium]   1 Preferred Generic $5.00$10.00Q:180
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   2 Generic $14.00$28.00Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2 Generic $14.00$28.00Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS   2 Generic $14.00$28.00None
DICLOFENAC POT 50 MG TABLET   3 Preferred Brand $47.00$94.00None
DICLOFENAC SOD EC 25 MG TAB   2 Generic $14.00$28.00None
DICLOFENAC SOD EC 50 MG TAB   2 Generic $14.00$28.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DICLOFENAC SOD EC 75 MG TAB   2 Generic $14.00$28.00None
Diclofenac Sodium 1% gel   3 Preferred Brand $47.00$94.00None
Diclofenac Sodium 3% gel   5 Specialty Tier 29%N/ANone
DICLOXACILLIN 250MG CAPSULE   3 Preferred Brand $47.00$94.00None
DICLOXACILLIN SODIUM 500MG CAP   3 Preferred Brand $47.00$94.00None
DICYCLOMINE 10 MG CAPSULE   1 Preferred Generic $5.00$10.00None
DICYCLOMINE 20 MG TABLET   2 Generic $14.00$28.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   4 Non-Preferred Drug 50%50%None
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   4 Non-Preferred Drug 50%50%None
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   4 Non-Preferred Drug 50%50%None
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 29%N/AP
DIGITEK 125 MCG TABLET   2 Generic $14.00$28.00Q:30
/30Days
DIGITEK 250 MCG TABLET   2 Generic $14.00$28.00P
DIGOX 125 MCG TABLET   2 Generic $14.00$28.00Q:30
/30Days
DIGOX 250 MCG TABLET   2 Generic $14.00$28.00P
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   3 Preferred Brand $47.00$94.00None
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $14.00$28.00Q:30
/30Days
DIGOXIN 250 MCG TABLET [Lanoxin]   2 Generic $14.00$28.00P
DIHYDROERGOTAMINE 1 MG/ML AM   5 Specialty Tier 29%N/AP
DILANTIN CAPSULES 30 MG ER   3 Preferred Brand $47.00$94.00None
DILT XR 120 MG CAPSULE   3 Preferred Brand $47.00$94.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DILT XR 180 MG CAPSULE   3 Preferred Brand $47.00$94.00None
DILT XR 240 MG CAPSULE   3 Preferred Brand $47.00$94.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $14.00$28.00None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   4 Non-Preferred Drug 50%50%None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 50%50%None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 50%50%None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   2 Generic $14.00$28.00None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   2 Generic $14.00$28.00None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   2 Generic $14.00$28.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   2 Generic $14.00$28.00None
DILTIAZEM 24HR ER 360 MG CAP [Tiazac]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DILTIAZEM 24HR ER 420 MG CAP [Tiazac]   3 Preferred Brand $47.00$94.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $14.00$28.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $14.00$28.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $14.00$28.00None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $47.00$94.00None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $47.00$94.00None
diphenhydramine 50 mg/ml vial   4 Non-Preferred Drug 50%50%None
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE   3 Preferred Brand $47.00$94.00None
DIPHENOXYLATE/ATROPINE LIQ   3 Preferred Brand $47.00$94.00None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $47.00$94.00None
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand $47.00$94.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIPYRIDAMOLE 25 MG TABLET   3 Preferred Brand $47.00$94.00None
DIPYRIDAMOLE 50 MG TABLET   3 Preferred Brand $47.00$94.00None
DIPYRIDAMOLE 75 MG TABLET   3 Preferred Brand $47.00$94.00None
DISOPYRAMIDE 100 MG CAPSULE   4 Non-Preferred Drug 50%50%None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)   4 Non-Preferred Drug 50%50%None
DISULFIRAM 250 MG TABLET   4 Non-Preferred Drug 50%50%None
DISULFIRAM 500 MG TABLET   4 Non-Preferred Drug 50%50%None
DIURIL 250MG/5ML SUSPENSION ORAL   4 Non-Preferred Drug 50%50%None
DIVALPROEX DR 125 MG CAP SPRNK   4 Non-Preferred Drug 50%50%None
DIVALPROEX SOD DR 125 MG TAB   2 Generic $14.00$28.00None
DIVALPROEX SOD DR 250 MG TAB   2 Generic $14.00$28.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIVALPROEX SOD DR 500 MG TAB   2 Generic $14.00$28.00None
DIVALPROEX SOD ER 500 MG TAB   4 Non-Preferred Drug 50%50%None
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   4 Non-Preferred Drug 50%50%None
DOCETAXEL 160 MG/16 ML VIAL   5 Specialty Tier 29%N/AP
Docetaxel 80 mg/4 ml vial   5 Specialty Tier 29%N/AP
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 50%50%None
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 50%50%None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 50%50%None
DONEPEZIL HCL 10 MG TABLET   2 Generic $14.00$28.00None
DONEPEZIL HCL 5 MG TABLET   2 Generic $14.00$28.00None
DONEPEZIL HCL ODT 10 MG TABLET   2 Generic $14.00$28.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DONEPEZIL HCL ODT 5 MG TABLET   2 Generic $14.00$28.00None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2 Generic $14.00$28.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   2 Generic $14.00$28.00None
DOXAZOSIN MESYLATE 1 MG TAB   2 Generic $14.00$28.00None
DOXAZOSIN MESYLATE 2 MG TAB   2 Generic $14.00$28.00None
DOXAZOSIN MESYLATE 4 MG TAB   2 Generic $14.00$28.00None
DOXAZOSIN MESYLATE 8 MG TAB   2 Generic $14.00$28.00None
DOXEPIN 10 MG/ML ORAL CONC   1 Preferred Generic $5.00$10.00P
DOXEPIN 10MG CAPSULE   3 Preferred Brand $47.00$94.00P
DOXEPIN 50 MG CAPSULE   3 Preferred Brand $47.00$94.00P
DOXEPIN 75MG CAPSULE   3 Preferred Brand $47.00$94.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DOXEPIN HCL 25MG CAPSULE (100 CT)   3 Preferred Brand $47.00$94.00P
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $47.00$94.00P
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   3 Preferred Brand $47.00$94.00P
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 25 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P
Doxorubicin liposome 20mg/10ml   4 Non-Preferred Drug 50%50%P
DOXY 100 VIAL   4 Non-Preferred Drug 50%50%None
DOXYCYCLINE HYCLATE 100 MG CAP   3 Preferred Brand $47.00$94.00None
DOXYCYCLINE HYCLATE 100 MG TAB   3 Preferred Brand $47.00$94.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   3 Preferred Brand $47.00$94.00None
DOXYCYCLINE HYCLATE 50 MG CAP   3 Preferred Brand $47.00$94.00None
DOXYCYCLINE MONO 100 MG CAP   2 Generic $14.00$28.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DOXYCYCLINE MONO 100 MG TABLET   3 Preferred Brand $47.00$94.00None
DOXYCYCLINE MONO 50 MG CAP   2 Generic $14.00$28.00None
DOXYCYCLINE MONO 50 MG TABLET   3 Preferred Brand $47.00$94.00None
DRONABINOL CAPS 10MG   5 Specialty Tier 29%N/AP Q:4
/1Days
DRONABINOL CAPS 2.5MG   4 Non-Preferred Drug 50%50%P Q:6
/1Days
DRONABINOL CAPS 5MG   4 Non-Preferred Drug 50%50%P Q:6
/1Days
DROSPIRENONE-EE 3-0.02 MG TAB   3 Preferred Brand $47.00$94.00None
DROSPIRENONE-EE 3-0.03 MG TAB   2 Generic $14.00$28.00None
DULERA INHALATION AEROSOL   4 Non-Preferred Drug 50%50%P
DULERA INHALATION AEROSOL   4 Non-Preferred Drug 50%50%P
DULOXETINE HCL DR 20 MG CAP [Cymbalta]   2 Generic $14.00$28.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DULOXETINE HCL DR 30 MG CAP [Cymbalta]   2 Generic $14.00$28.00None
DULOXETINE HCL DR 60 MG CAP [Cymbalta]   2 Generic $14.00$28.00None
DUPIXENT 300 MG/2 ML SAFE SYRG   5 Specialty Tier 29%N/AP
DUREZOL 0.05% EYE DROPS   3 Preferred Brand $47.00$94.00None
DUTASTERIDE 0.5 MG CAPSULE   2 Generic $14.00$28.00None
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn]   4 Non-Preferred Drug 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D HealthPartners Freedom Ultimate with Enhanced Rx (Cost) 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2018 )

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.