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2019 Medicare Part D Plan Formulary Information
BlueRx Enhanced (PDP) (S1030-010-0)
Benefit Details           
The BlueRx Enhanced (PDP) (S1030-010-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $71.50 Deductible: $350 Qualifies for LIS: No
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   3 Preferred Brand $40.00$80.00Q:120
/30Days
D-AMPHETAMINE ER 15 MG CAPSULE   3 Preferred Brand $40.00$80.00Q:120
/30Days
D-AMPHETAMINE ER 5 MG CAPSULE   2 Generic $4.00$8.00Q:90
/30Days
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN   4 Non-Preferred Drug 45%45%None
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN   4 Non-Preferred Drug 45%45%None
DAKLINZA 30 MG TABLET   5 Specialty Tier 25%25%P
DAKLINZA 60 MG TABLET   5 Specialty Tier 25%25%P
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 25%25%P
DALIRESP 250 MCG TABLET   4 Non-Preferred Drug 45%45%P Q:30
/30Days
DALIRESP 500 MCG TABLET   4 Non-Preferred Drug 45%45%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DALVANCE 500 MG VIAL   5 Specialty Tier 25%25%None
DANAZOL 100 MG CAPSULE   3 Preferred Brand $40.00$80.00P
DANAZOL 50MG CAPSULE   3 Preferred Brand $40.00$80.00P
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 45%45%P
DANTROLENE SODIUM 100MG CAPSULE   2 Generic $4.00$8.00None
DANTROLENE SODIUM 25MG CAPSULE   2 Generic $4.00$8.00None
DANTROLENE SODIUM 50MG CAPSULE   2 Generic $4.00$8.00None
DAPSONE 25 MG TABLET   2 Generic $4.00$8.00None
DAPSONE TABLETS 100MG 30 BLPK   2 Generic $4.00$8.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand $40.00$80.00None
DAPTOMYCIN 500 MG VIAL [Cubicin]   5 Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DARAPRIM 25 MG TABLET   5 Specialty Tier 25%25%None
DAURISMO 100 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
DAURISMO 25 MG TABLET   5 Specialty Tier 25%25%P Q:60
/30Days
DEBLITANE 0.35 MG TABLET   2 Generic $4.00$8.00None
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%25%P
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%25%P
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%25%P
DELSTRIGO 100-300-300 MG TABLET   5 Specialty Tier 25%25%Q:30
/30Days
Delyla-28 tablet   2 Generic $4.00$8.00None
DELZICOL DR 400 MG CAPSULE   3 Preferred Brand $40.00$80.00None
DEMECLOCYCLINE 150 MG TABLET   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEMECLOCYCLINE 300 MG TABLET   4 Non-Preferred Drug 45%45%None
DEMSER CAPSULES 250MG (100 CT)   5 Specialty Tier 25%25%None
DENAVIR 1% CREAM (g)   5 Specialty Tier 25%25%None
DEPEN 250MG TITRATAB   5 Specialty Tier 25%25%None
DEPO-PROVERA 400MG/ML VIAL   4 Non-Preferred Drug 45%45%None
DESCOVY 200-25 MG TABLET   5 Specialty Tier 25%25%Q:30
/30Days
DESIPRAMINE 10 MG TABLET [Norpramin]   3 Preferred Brand $40.00$80.00P
DESIPRAMINE 100 MG TABLET [Norpramin]   3 Preferred Brand $40.00$80.00P
DESIPRAMINE 150 MG TABLET [Norpramin]   3 Preferred Brand $40.00$80.00P
DESIPRAMINE 25 MG TABLET [Norpramin]   3 Preferred Brand $40.00$80.00P
DESIPRAMINE 50 MG TABLET [Norpramin]   3 Preferred Brand $40.00$80.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE 75 MG TABLET [Norpramin]   3 Preferred Brand $40.00$80.00P
DESMOPRESSIN ACETATE 0.1 MG TB   2 Generic $4.00$8.00None
DESMOPRESSIN ACETATE 0.2 MG TB   2 Generic $4.00$8.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   3 Preferred Brand $40.00$80.00None
DESOGESTR-ETH ESTRA 0.15-0.03MG   2 Generic $4.00$8.00None
DESOGESTR-ETH ESTRAD   2 Generic $4.00$8.00None
Desonide 0.0005 MG/MG Topical Ointment   3 Preferred Brand $40.00$80.00None
DESONIDE 0.05% CREAM   3 Preferred Brand $40.00$80.00None
DESONIDE 0.05% LOTION   4 Non-Preferred Drug 45%45%None
DESOXIMETASONE 0.25% CREAM   2 Generic $4.00$8.00None
DESOXIMETASONE 0.25% OINTMENT   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   3 Preferred Brand $40.00$80.00None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   3 Preferred Brand $40.00$80.00None
Desvenlafaxine Succinate ER 100 mg [Pristiq]   2 Generic $4.00$8.00Q:30
/30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   2 Generic $4.00$8.00Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   2 Generic $4.00$8.00Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   3 Preferred Brand $40.00$80.00None
DEXAMETHASONE 0.5MG TABLET   1 Preferred Generic $1.00$2.00None
DEXAMETHASONE 0.5MG/5ML ELX   2 Generic $4.00$8.00None
DEXAMETHASONE 0.75MG TABLET   1 Preferred Generic $1.00$2.00None
DEXAMETHASONE 1.5MG TABLET   1 Preferred Generic $1.00$2.00None
DEXAMETHASONE 1MG TABLET   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 2MG TABLET   3 Preferred Brand $40.00$80.00None
DEXAMETHASONE 4MG TABLET   1 Preferred Generic $1.00$2.00None
DEXAMETHASONE 6MG TABLET   1 Preferred Generic $1.00$2.00None
DEXMETHYLPHENIDATE HCL 10MG TABLET   2 Generic $4.00$8.00Q:60
/30Days
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   2 Generic $4.00$8.00Q:60
/30Days
DEXMETHYLPHENIDATE HCL 5MG TABLET   2 Generic $4.00$8.00Q:60
/30Days
DEXTROAMP-AMPHET ER 10 MG CAP   2 Generic $4.00$8.00Q:30
/30Days
DEXTROAMP-AMPHET ER 15 MG CAP   2 Generic $4.00$8.00Q:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAP   3 Preferred Brand $40.00$80.00Q:30
/30Days
DEXTROAMP-AMPHET ER 25 MG CAP   3 Preferred Brand $40.00$80.00Q:30
/30Days
DEXTROAMP-AMPHET ER 30 MG CAP   3 Preferred Brand $40.00$80.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMP-AMPHET ER 5 MG CAP   2 Generic $4.00$8.00Q:30
/30Days
DEXTROAMP-AMPHETAMIN 20 MG TAB   2 Generic $4.00$8.00Q:90
/30Days
DEXTROAMP-AMPHETAMIN 30 MG TAB   2 Generic $4.00$8.00Q:60
/30Days
DEXTROAMPHETAMINE 10 MG TAB   2 Generic $4.00$8.00Q:180
/30Days
DEXTROAMPHETAMINE 5 MG TAB   2 Generic $4.00$8.00Q:90
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   2 Generic $4.00$8.00Q:60
/30Days
Dextrose 10%-water iv solution   2 Generic $4.00$8.00None
DEXTROSE 2.5%-1/2NS IV SOLUTION   1 Preferred Generic $1.00$2.00None
DEXTROSE 5%-0.45% NACL IV SOLN   1 Preferred Generic $1.00$2.00None
DEXTROSE 5%-0.9% NACL IV SOLN   1 Preferred Generic $1.00$2.00None
DEXTROSE 5%-WATER IV SOLN   2 Generic $4.00$8.00None
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 Preferred Generic $1.00$2.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   3 Preferred Brand $40.00$80.00None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 45%45%Q:5
/30Days
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 45%45%Q:5
/30Days
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Drug 45%45%Q:5
/30Days
DIAZEPAM 10 MG TABLET [Valium]   1 Preferred Generic $1.00$2.00P Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   1 Preferred Generic $1.00$2.00P Q:120
/30Days
DIAZEPAM 5 MG TABLET [Valium]   1 Preferred Generic $1.00$2.00P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   3 Preferred Brand $40.00$80.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2 Generic $4.00$8.00P Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC POT 50 MG TABLET   2 Generic $4.00$8.00Q:120
/30Days
DICLOFENAC SOD EC 25 MG TAB   2 Generic $4.00$8.00Q:240
/30Days
DICLOFENAC SOD EC 50 MG TAB   2 Generic $4.00$8.00Q:120
/30Days
DICLOFENAC SOD EC 75 MG TAB   2 Generic $4.00$8.00Q:60
/30Days
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR]   2 Generic $4.00$8.00Q:60
/30Days
Diclofenac Sodium 1% gel   2 Generic $4.00$8.00P
Diclofenac Sodium 3% gel   5 Specialty Tier 25%25%None
diclofenac-misoprost 50-0.2 tablet   2 Generic $4.00$8.00Q:120
/30Days
diclofenac-misoprost 75-0.2 tablet   2 Generic $4.00$8.00Q:90
/30Days
DICLOXACILLIN 250MG CAPSULE   2 Generic $4.00$8.00None
DICLOXACILLIN SODIUM 500MG CAP   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICYCLOMINE 10 MG CAPSULE   3 Preferred Brand $40.00$80.00P
DICYCLOMINE 20 MG TABLET   4 Non-Preferred Drug 45%45%P
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   2 Generic $4.00$8.00Q:30
/30Days
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   2 Generic $4.00$8.00Q:30
/30Days
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   3 Preferred Brand $40.00$80.00Q:30
/30Days
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%25%None
DIFLORASONE 0.05% OINTMENT   4 Non-Preferred Drug 45%45%None
DIGITEK 125 MCG TABLET   2 Generic $4.00$8.00Q:30
/30Days
DIGITEK 250 MCG TABLET   4 Non-Preferred Drug 45%45%Q:30
/30Days
DIGOX 125 MCG TABLET   2 Generic $4.00$8.00Q:30
/30Days
DIGOX 250 MCG TABLET   4 Non-Preferred Drug 45%45%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   4 Non-Preferred Drug 45%45%Q:150
/30Days
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $4.00$8.00Q:30
/30Days
DIGOXIN 250 MCG TABLET [Lanoxin]   4 Non-Preferred Drug 45%45%Q:30
/30Days
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 45%45%None
DILT XR 120 MG CAPSULE   3 Preferred Brand $40.00$80.00None
DILT XR 180 MG CAPSULE   3 Preferred Brand $40.00$80.00None
DILT XR 240 MG CAPSULE   3 Preferred Brand $40.00$80.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $4.00$8.00None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 24HR ER 360 MG CAP [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 24HR ER 420 MG CAP [Tiazac]   3 Preferred Brand $40.00$80.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $4.00$8.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $4.00$8.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $4.00$8.00None
DIPENTUM 250 MG CAPSULE   5 Specialty Tier 25%25%None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $40.00$80.00None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $40.00$80.00None
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand $40.00$80.00None
DIPYRIDAMOLE 25 MG TABLET   4 Non-Preferred Drug 45%45%None
DIPYRIDAMOLE 50 MG TABLET   4 Non-Preferred Drug 45%45%None
DIPYRIDAMOLE 75 MG TABLET   4 Non-Preferred Drug 45%45%None
DISULFIRAM 250 MG TABLET   2 Generic $4.00$8.00None
DISULFIRAM 500 MG TABLET   2 Generic $4.00$8.00None
DIVALPROEX DR 125 MG CAP SPRNK   2 Generic $4.00$8.00None
DIVALPROEX SOD DR 125 MG TAB   2 Generic $4.00$8.00None
DIVALPROEX SOD DR 250 MG TAB   2 Generic $4.00$8.00None
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 $4.00$8.00None
DIVALPROEX SOD ER 500 MG TAB   2 Generic $4.00$8.00None
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   2 Generic $4.00$8.00None
DIVIGEL 1 MG GEL PACKET   4 Non-Preferred Drug 45%45%None
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 45%45%None
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 45%45%None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   3 Preferred Brand $40.00$80.00None
DONEPEZIL HCL 10 MG TABLET   1 Preferred Generic $1.00$2.00None
DONEPEZIL HCL 23 MG TABLET   3 Preferred Brand $40.00$80.00None
DONEPEZIL HCL 5 MG TABLET   1 Preferred Generic $1.00$2.00None
DONEPEZIL HCL ODT 10 MG TABLET   2 Generic $4.00$8.00None
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 $4.00$8.00None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2 Generic $4.00$8.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   2 Generic $4.00$8.00None
DOVATO 50-300 MG TABLET   5 Specialty Tier 25%25%Q:30
/30Days
DOXAZOSIN MESYLATE 1 MG TAB   2 Generic $4.00$8.00Q:60
/30Days
DOXAZOSIN MESYLATE 2 MG TAB   2 Generic $4.00$8.00Q:60
/30Days
DOXAZOSIN MESYLATE 4 MG TAB   2 Generic $4.00$8.00Q:60
/30Days
DOXAZOSIN MESYLATE 8 MG TAB   2 Generic $4.00$8.00Q:60
/30Days
DOXEPIN 10 MG/ML ORAL CONC   4 Non-Preferred Drug 45%45%P
DOXEPIN 10MG CAPSULE   4 Non-Preferred Drug 45%45%P
DOXEPIN 50 MG CAPSULE   4 Non-Preferred Drug 45%45%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 45%45%P
DOXEPIN HCL 25MG CAPSULE (100 CT)   4 Non-Preferred Drug 45%45%P
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 45%45%P
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   4 Non-Preferred Drug 45%45%P
DOXY 100 VIAL   3 Preferred Brand $40.00$80.00None
Doxycycline 75mg/1   4 Non-Preferred Drug 45%45%None
DOXYCYCLINE HYCLATE 100 MG CAP   2 Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 100 MG TAB   2 Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   2 Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 50 MG CAP   2 Generic $4.00$8.00None
DOXYCYCLINE MONO 100 MG CAP   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE MONO 100 MG TABLET   2 Generic $4.00$8.00None
DOXYCYCLINE MONO 150 MG TABLET   3 Preferred Brand $40.00$80.00None
DOXYCYCLINE MONO 50 MG CAP   2 Generic $4.00$8.00None
DOXYCYCLINE MONO 50 MG TABLET   2 Generic $4.00$8.00None
DOXYCYCLINE MONO 75 MG TABLET   2 Generic $4.00$8.00None
Doxycycline Monohydrate 150 MG Oral Capsule   4 Non-Preferred Drug 45%45%None
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 45%45%P
DRONABINOL 2.5 MG CAPSULE [Marinol]   3 Preferred Brand $40.00$80.00P
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 45%45%P
DROSP-EE-LEVOMEF 3-0.02-0.451 TABLET [Beyaz]   2 Generic $4.00$8.00None
DROSPIRENONE-EE 3-0.02 MG TAB   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DROSPIRENONE-EE 3-0.03 MG TAB   2 Generic $4.00$8.00None
DUAVEE 0.45-20 MG TABLET   4 Non-Preferred Drug 45%45%None
DULERA INHALATION AEROSOL   4 Non-Preferred Drug 45%45%Q:13
/30Days
DULERA INHALATION AEROSOL   4 Non-Preferred Drug 45%45%Q:13
/30Days
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $40.00$80.00Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $40.00$80.00Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $40.00$80.00Q:60
/30Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 25%25%P
DUPIXENT 300 MG/2 ML SAFE SYRG   5 Specialty Tier 25%25%P
duramorph 0.5 mg/ml ampule   3 Preferred Brand $40.00$80.00P
duramorph 1 mg/ml ampule   3 Preferred Brand $40.00$80.00P
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 $40.00$80.00None
DUTASTERIDE 0.5 MG CAPSULE   2 Generic $4.00$8.00Q:30
/30Days
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn]   2 Generic $4.00$8.00Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D BlueRx Enhanced (PDP) 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 $415 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" 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 2019 )

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.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.