2019 Medicare Part D Plan Formulary Information |
True Blue Rx Option I (HMO) (H1350-015-1)
Benefit Details
|
The True Blue Rx Option I (HMO) (H1350-015-1) Formulary Drugs Starting with the Letter D in Payette County, ID: CMS MA Region 23 which includes: ID Plan Monthly Premium: $139.00 Deductible: $0 |
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 |
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN |
2 |
Generic |
$6.00 | $18.00 | None |
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN |
2 |
Generic |
$6.00 | $18.00 | None |
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra] |
5 |
Specialty Tier |
33% | N/A | P |
DALIRESP 250 MCG TABLET |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DALIRESP 500 MCG TABLET |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DALVANCE 500 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
DANAZOL 100 MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DANAZOL 50MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
2 |
Generic |
$6.00 | $18.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTROLENE SODIUM 25MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DAPSONE 25 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DAPSONE 5% GEL |
2 |
Generic |
$6.00 | $18.00 | None |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Generic |
$6.00 | $18.00 | None |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DAPTOMYCIN 350 MG VIAL [Cubicin RF] |
5 |
Specialty Tier |
33% | N/A | None |
DAPTOMYCIN 500 MG VIAL [Cubicin] |
5 |
Specialty Tier |
33% | N/A | None |
DARIFENACIN ER 15 MG TABLET [Enablex] |
2 |
Generic |
$6.00 | $18.00 | None |
DARIFENACIN ER 7.5 MG TABLET [Enablex] |
2 |
Generic |
$6.00 | $18.00 | None |
DAURISMO 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAURISMO 25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
DAYTRANA PATCH 1.1 MG/HR |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:30 /30Days |
DAYTRANA PATCH 1.6 MG/HR |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:30 /30Days |
DAYTRANA PATCH 2.2 MG/HR |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:30 /30Days |
DAYTRANA PATCH 3.3 MG/HR |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:30 /30Days |
DEBLITANE 0.35 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DEFERASIROX 125 MG TABLET DISPER [Exjade] |
5 |
Specialty Tier |
33% | N/A | P |
DEFERASIROX 250 MG TABLET DISPER [Exjade] |
5 |
Specialty Tier |
33% | N/A | P |
DEFERASIROX 500 MG TABLET DISPER [Exjade] |
5 |
Specialty Tier |
33% | N/A | P |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Delyla-28 tablet |
2 |
Generic |
$6.00 | $18.00 | None |
DELZICOL DR 400 MG CAPSULE |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DEMECLOCYCLINE 150 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DEMECLOCYCLINE 300 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Specialty Tier |
33% | N/A | P |
DENAVIR 1% CREAM (g) |
5 |
Specialty Tier |
33% | N/A | None |
DEPEN 250MG TITRATAB |
5 |
Specialty Tier |
33% | N/A | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | P |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESCOVY 200-25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 10 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESIPRAMINE 100 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESIPRAMINE 150 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESIPRAMINE 25 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESIPRAMINE 50 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESIPRAMINE 75 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DESLORATADINE 2.5 MG ODDT |
2 |
Generic |
$6.00 | $18.00 | None |
DESLORATADINE 5 MG ODDT |
2 |
Generic |
$6.00 | $18.00 | None |
DESLORATADINE 5 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DESMOPRESSIN ACETATE 0.1 MG TB |
2 |
Generic |
$6.00 | $18.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TB |
2 |
Generic |
$6.00 | $18.00 | 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 |
$6.00 | $18.00 | None |
DESOGESTR-ETH ESTRA 0.15-0.03MG |
2 |
Generic |
$6.00 | $18.00 | None |
DESOGESTR-ETH ESTRAD |
2 |
Generic |
$6.00 | $18.00 | None |
DESONATE 0.05% GEL |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
Desonide 0.0005 MG/MG Topical Ointment |
2 |
Generic |
$6.00 | $18.00 | None |
DESONIDE 0.05% CREAM |
2 |
Generic |
$6.00 | $18.00 | None |
DESONIDE 0.05% LOTION |
2 |
Generic |
$6.00 | $18.00 | None |
DESOXIMETASONE 0.25% SPRAY [Topicort] |
2 |
Generic |
$6.00 | $18.00 | None |
Desvenlafaxine Succinate ER 100 mg [Pristiq] |
2 |
Generic |
$6.00 | $18.00 | P |
Desvenlafaxine Succinate ER 25 mg tb [Pristiq] |
2 |
Generic |
$6.00 | $18.00 | P |
Desvenlafaxine Succinate ER 50 mg tb [Pristiq] |
2 |
Generic |
$6.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.1% EYE DROP |
2 |
Generic |
$6.00 | $18.00 | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 0.5MG/0.5ML DROP |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2 |
Generic |
$6.00 | $18.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 1MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 2MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 4MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXILANT DR 60 MG CAPSULE |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 10 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE ER 15 MG CP |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
Dexmethylphenidate er 20 mg cp |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
Dexmethylphenidate er 25 mg cp |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 30 MG CP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Dexmethylphenidate er 35 mg cp |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 40 MG CP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE ER 5 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
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:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:120 /30Days |
DEXTROAMP-AMPHET ER 10 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:90 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP |
2 |
Generic |
$6.00 | $18.00 | Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 20 MG TAB |
2 |
Generic |
$6.00 | $18.00 | Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 30 MG TAB |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $18.00 | Q:180 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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%-0.45% NACL IV SOLN |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE 5%-0.9% NACL IV SOLN |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
2 |
Generic |
$6.00 | $18.00 | None |
DEXTROSE 5%-WATER IV SOLN |
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 |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | 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 |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DIAZEPAM 10 MG TABLET [Valium] |
2 |
Generic |
$6.00 | $18.00 | P Q:120 /30Days |
DIAZEPAM 2 MG TABLET [Valium] |
2 |
Generic |
$6.00 | $18.00 | P Q:120 /30Days |
DIAZEPAM 5 MG TABLET [Valium] |
2 |
Generic |
$6.00 | $18.00 | P Q:120 /30Days |
DIAZEPAM 5 MG/5 ML SOLUTION |
2 |
Generic |
$6.00 | $18.00 | P Q:1200 /30Days |
DIAZEPAM 5 MG/ML ORAL CONC |
2 |
Generic |
$6.00 | $18.00 | P Q:240 /30Days |
DICLOFENAC 0.1% EYE DROPS [Voltaren] |
2 |
Generic |
$6.00 | $18.00 | None |
DICLOFENAC POT 50 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:120 /30Days |
DICLOFENAC SOD EC 25 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DICLOFENAC SOD EC 50 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DICLOFENAC SOD EC 75 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 |
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR] |
2 |
Generic |
$6.00 | $18.00 | None |
Diclofenac sodium 1.5% soln |
2 |
Generic |
$6.00 | $18.00 | P |
Diclofenac Sodium 1% gel |
2 |
Generic |
$6.00 | $18.00 | P |
diclofenac-misoprost 50-0.2 tablet |
2 |
Generic |
$6.00 | $18.00 | None |
diclofenac-misoprost 75-0.2 tablet |
2 |
Generic |
$6.00 | $18.00 | None |
DICLOXACILLIN 250MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DICYCLOMINE 10 MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DICYCLOMINE 20 MG TABLET |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC] |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIDANOSINE DR 250 MG CAPSULE [Videx EC] |
2 |
Generic |
$6.00 | $18.00 | None |
DIDANOSINE DR 400 MG CAPSULE [Videx EC] |
2 |
Generic |
$6.00 | $18.00 | None |
DIFFERIN LOTION |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
DIFLUNISAL 500 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DIGITEK 125 MCG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DIGITEK 250 MCG TABLET |
2 |
Generic |
$6.00 | $18.00 | P |
DIGOX 125 MCG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
DIGOX 250 MCG TABLET |
2 |
Generic |
$6.00 | $18.00 | P |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
2 |
Generic |
$6.00 | $18.00 | P |
DIGOXIN 125 MCG TABLET [Lanoxin] |
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 |
DIGOXIN 250 MCG TABLET [Lanoxin] |
2 |
Generic |
$6.00 | $18.00 | P |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
5 |
Specialty Tier |
33% | N/A | Q:8 /30Days |
DILANTIN 50MG INFATAB |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DILANTIN CAPSULES 30 MG ER |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DILANTIN-125 SUS 125/5ML |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DILT XR 120 MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DILT XR 180 MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DILT XR 240 MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
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 12HR ER 60 MG CAPSULE [Cardizem SR] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 24HR ER 360 MG CAP [Tiazac] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 24HR ER 420 MG CAP [Tiazac] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
2 |
Generic |
$6.00 | $18.00 | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPENTUM 250 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Preferred Brand |
$35.00 | $105.00 | P |
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus |
3 |
Preferred Brand |
$35.00 | $105.00 | P |
DISOPYRAMIDE 100 MG CAPSULE |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DISULFIRAM 250 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DISULFIRAM 500 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 |
DIURIL 250MG/5ML SUSPENSION ORAL |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DIVALPROEX DR 125 MG CAP SPRNK |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SOD DR 125 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SOD DR 250 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SOD DR 500 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SOD ER 500 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT |
2 |
Generic |
$6.00 | $18.00 | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
2 |
Generic |
$6.00 | $18.00 | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
2 |
Generic |
$6.00 | $18.00 | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
2 |
Generic |
$6.00 | $18.00 | None |
DONEPEZIL HCL 10 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 |
DONEPEZIL HCL 23 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DONEPEZIL HCL 5 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DONEPEZIL HCL ODT 10 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DONEPEZIL HCL ODT 5 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DOPTELET 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
DOPTELET 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
DORIPENEM 500 MG VIAL [Doribax] |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
2 |
Generic |
$6.00 | $18.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2 |
Generic |
$6.00 | $18.00 | None |
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF] |
2 |
Generic |
$6.00 | $18.00 | None |
DOVATO 50-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXAZOSIN MESYLATE 1 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXAZOSIN MESYLATE 2 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXAZOSIN MESYLATE 4 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXAZOSIN MESYLATE 8 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXEPIN 10 MG/ML ORAL CONC |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DOXEPIN 10MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DOXEPIN 50 MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DOXEPIN 75MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
2 |
Generic |
$6.00 | $18.00 | P |
Doxercalciferol 1 mcg capsule [HECTOROL] |
2 |
Generic |
$6.00 | $18.00 | P |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
2 |
Generic |
$6.00 | $18.00 | P |
DOXY 100 VIAL |
2 |
Generic |
$6.00 | $18.00 | None |
doxycycline 25 mg/5 ml susp |
2 |
Generic |
$6.00 | $18.00 | None |
Doxycycline 75mg/1 |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYC DR 100 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYC DR 150 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYC DR 200 MG TABLET DR [Doryx] |
2 |
Generic |
$6.00 | $18.00 | None |
Doxycycline hyc dr 50 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYC DR 75 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 |
DOXYCYCLINE HYCLATE 100 MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYCLATE 100 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE HYCLATE 50 MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE MONO 100 MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE MONO 100 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE MONO 150 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE MONO 50 MG CAP |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE MONO 50 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
DOXYCYCLINE MONO 75 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
Doxycycline Monohydrate 150 MG Oral Capsule |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL 10 MG CAPSULE [Marinol] |
2 |
Generic |
$6.00 | $18.00 | P Q:60 /30Days |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
2 |
Generic |
$6.00 | $18.00 | P Q:60 /30Days |
DRONABINOL 5 MG CAPSULE [Marinol] |
2 |
Generic |
$6.00 | $18.00 | P Q:60 /30Days |
DROSP-EE-LEVOMEF 3-0.02-0.451 TABLET [Beyaz] |
2 |
Generic |
$6.00 | $18.00 | None |
DROSPIRENONE-EE 3-0.02 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DROSPIRENONE-EE 3-0.03 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
DROXIA 200MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DROXIA 300MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DROXIA 400MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DULERA INHALATION AEROSOL |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:13 /30Days |
DULERA INHALATION AEROSOL |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:13 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta] |
2 |
Generic |
$6.00 | $18.00 | Q:180 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta] |
2 |
Generic |
$6.00 | $18.00 | Q:120 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta] |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
DUOPA 4.63 MG-20 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | P |
DUREZOL 0.05% EYE DROPS |
3 |
Preferred Brand |
$35.00 | $105.00 | None |
DUTASTERIDE 0.5 MG CAPSULE |
2 |
Generic |
$6.00 | $18.00 | None |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn] |
2 |
Generic |
$6.00 | $18.00 | None |
DUTOPROL 100-12.5 MG TABLET |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DUTOPROL 25-12.5 MG TABLET |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DUTOPROL 50-12.5 MG TABLET |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DVORAH 325-30-16 MG TABLET [Panlor] |
2 |
Generic |
$6.00 | $18.00 | Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYANAVEL XR 2.5 MG/ML SUSP |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:240 /30Days |
DYMISTA NASAL SPRAY |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:23 /30Days |
DYRENIUM 100 MG CAPSULE |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |
DYRENIUM 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None |