2019 Medicare Part D Plan Formulary Information |
BlueMedicare Complete Rx (PDP) (S5904-002-0)
Benefit Details
|
The BlueMedicare Complete Rx (PDP) (S5904-002-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $155.90 Deductible: $0 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 |
2 |
Generic |
$10.00 | $30.00 | Q:120 /30Days |
D-AMPHETAMINE ER 15 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | Q:120 /30Days |
D-AMPHETAMINE ER 5 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN |
2 |
Generic |
$10.00 | $30.00 | None |
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN |
2 |
Generic |
$10.00 | $30.00 | None |
DAKLINZA 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
DAKLINZA 60 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra] |
5 |
Specialty Tier |
33% | N/A | P |
DALIRESP 250 MCG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P Q:30 /30Days |
DALIRESP 500 MCG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | 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 |
33% | N/A | None |
DANAZOL 100 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | P |
DANAZOL 50MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | P |
DANAZOL CAPSULES USP 200MG (100 CT) |
2 |
Generic |
$10.00 | $30.00 | P |
DANTRIUM 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DANTRIUM 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DAPSONE 25 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DAPSONE TABLETS 100MG 30 BLPK |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPTACEL VACCINE 15;5;5;3; LF/.5ML |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
DAPTOMYCIN 500 MG VIAL [Cubicin] |
5 |
Specialty Tier |
33% | N/A | None |
DARAPRIM 25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
DAURISMO 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
DAURISMO 25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
DAYPRO 600MG CAPLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:90 /30Days |
DDAVP 0.01% NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | None |
DDAVP 0.1 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DDAVP 0.2 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEBLITANE 0.35 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DEFERASIROX 125 MG TABLET DISPER [Exjade] |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
Delyla-28 tablet |
2 |
Generic |
$10.00 | $30.00 | None |
DELZICOL DR 400 MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
DEMECLOCYCLINE 150 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DEMECLOCYCLINE 300 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Specialty Tier |
33% | N/A | None |
DENAVIR 1% CREAM (g) |
5 |
Specialty Tier |
33% | N/A | None |
DEPAKENE 250MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPAKOTE 125MG SPRINKLE CAP |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPAKOTE 125MG TABLET EC |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPAKOTE DR 250 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPAKOTE DR 500 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPAKOTE ER 250MG TABLET SA |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPAKOTE ER 500MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPEN 250MG TITRATAB |
5 |
Specialty Tier |
33% | N/A | None |
DEPO-PROVERA 150 MG/ML VIAL |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DEPO-TESTOSTERONE 100 MG/ML VL VIAL |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DEPO-TESTOSTERONE 200 MG/ML VL VIAL |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DESCOVY 200-25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 10 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DESIPRAMINE 100 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DESIPRAMINE 150 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DESIPRAMINE 25 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DESIPRAMINE 50 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DESIPRAMINE 75 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DESLORATADINE 5 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DESMOPRESSIN ACETATE 0.1 MG TB |
2 |
Generic |
$10.00 | $30.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TB |
2 |
Generic |
$10.00 | $30.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
2 |
Generic |
$10.00 | $30.00 | None |
DESOGESTR-ETH ESTRA 0.15-0.03MG |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOGESTR-ETH ESTRAD |
2 |
Generic |
$10.00 | $30.00 | None |
Desonide 0.0005 MG/MG Topical Ointment |
2 |
Generic |
$10.00 | $30.00 | None |
DESONIDE 0.05% CREAM |
2 |
Generic |
$10.00 | $30.00 | None |
DESONIDE 0.05% LOTION |
2 |
Generic |
$10.00 | $30.00 | None |
DESOXIMETASONE 0.25% CREAM |
2 |
Generic |
$10.00 | $30.00 | None |
DESOXIMETASONE 0.25% OINTMENT |
2 |
Generic |
$10.00 | $30.00 | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$10.00 | $30.00 | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$10.00 | $30.00 | None |
Desvenlafaxine Succinate ER 100 mg [Pristiq] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
Desvenlafaxine Succinate ER 25 mg tb [Pristiq] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
Desvenlafaxine Succinate ER 50 mg tb [Pristiq] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DETROL 1 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:60 /30Days |
DETROL 2 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:60 /30Days |
DETROL LA 2 MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DETROL LA 4 MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DEXAMETHASONE 0.1% EYE DROP |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
DEXAMETHASONE 0.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2 |
Generic |
$10.00 | $30.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 1.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 1MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
DEXAMETHASONE 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 4MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXAMETHASONE 6MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXEDRINE SPANSULE 10 MG CAPSULE ER |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
DEXEDRINE SPANSULE 15 MG CAPSULE ER |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
DEXEDRINE SPANSULE 5 MG CAPSULE ER |
5 |
Specialty Tier |
33% | N/A | Q:90 /30Days |
DEXMETHYLPHENIDATE HCL 10MG TABLET |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 2.5MG TABLET |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE HCL 5MG TABLET |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DEXTROAMP-AMPHET ER 10 MG CAP |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAP |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAP |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 25 MG CAP |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAP |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DEXTROAMP-AMPHET ER 5 MG CAP |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DEXTROAMP-AMPHETAMIN 20 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 30 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DEXTROAMPHETAMINE 10 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:180 /30Days |
DEXTROAMPHETAMINE 5 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Dextrose 10%-water iv solution |
2 |
Generic |
$10.00 | $30.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXTROSE 5%-0.45% NACL IV SOLN |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 5%-0.9% NACL IV SOLN |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXTROSE 5%-WATER IV SOLN |
2 |
Generic |
$10.00 | $30.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:5 /30Days |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:5 /30Days |
DIASTAT ACUDIAL 5-7.5-10 MG KT |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:5 /30Days |
DIAZEPAM 10 MG TABLET [Valium] |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
DIAZEPAM 2 MG TABLET [Valium] |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
DIAZEPAM 5 MG TABLET [Valium] |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
DIAZEPAM 5 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:1200 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIAZEPAM 5 MG/ML ORAL CONC |
2 |
Generic |
$10.00 | $30.00 | P Q:240 /30Days |
DICLOFENAC 0.1% EYE DROPS [Voltaren] |
2 |
Generic |
$10.00 | $30.00 | None |
DICLOFENAC POT 50 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | Q:120 /30Days |
DICLOFENAC SOD EC 25 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:240 /30Days |
DICLOFENAC SOD EC 50 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:120 /30Days |
DICLOFENAC SOD EC 75 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR] |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Diclofenac Sodium 1% gel |
2 |
Generic |
$10.00 | $30.00 | P |
Diclofenac Sodium 3% gel |
5 |
Specialty Tier |
33% | N/A | None |
diclofenac-misoprost 50-0.2 tablet |
2 |
Generic |
$10.00 | $30.00 | Q:120 /30Days |
diclofenac-misoprost 75-0.2 tablet |
2 |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOXACILLIN 250MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DICLOXACILLIN SODIUM 500MG CAP |
2 |
Generic |
$10.00 | $30.00 | None |
DICYCLOMINE 10 MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DICYCLOMINE 20 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DIDANOSINE DR 250 MG CAPSULE [Videx EC] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DIDANOSINE DR 400 MG CAPSULE [Videx EC] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
DIFLORASONE 0.05% OINTMENT |
2 |
Generic |
$10.00 | $30.00 | None |
DIFLUCAN 100MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIFLUCAN 150MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLUCAN 200MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIFLUCAN 200MG/5ML SUSPEN |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIFLUCAN 50MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIFLUCAN 50MG/5ML SUSPEN |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIGITEK 125 MCG TABLET |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DIGITEK 250 MCG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIGOX 125 MCG TABLET |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DIGOX 250 MCG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:150 /30Days |
DIGOXIN 125 MCG TABLET [Lanoxin] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DIGOXIN 250 MCG TABLET [Lanoxin] |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILANTIN 50MG INFATAB |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DILANTIN CAPSULES 30 MG ER |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DILANTIN-125 SUS 125/5ML |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DILT XR 120 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DILT XR 180 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DILT XR 240 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 24HR ER 360 MG CAP [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 24HR ER 420 MG CAP [Tiazac] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
2 |
Generic |
$10.00 | $30.00 | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
2 |
Generic |
$10.00 | $30.00 | None |
DIOVAN 160MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:60 /30Days |
DIOVAN 320MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN 40MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:60 /30Days |
DIOVAN 80MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:60 /30Days |
DIOVAN HCT 160/12.5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIOVAN HCT 160/25MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIOVAN HCT 320/12.5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIOVAN HCT 320/25MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIOVAN HCT 80/12.5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
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 |
$40.00 | $120.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
DIPROLENE 0.05% OINTMENT |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIPYRIDAMOLE 25 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIPYRIDAMOLE 50 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DIPYRIDAMOLE 75 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DISULFIRAM 250 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DISULFIRAM 500 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DITROPAN XL 10 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:90 /30Days |
DITROPAN XL 5 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days |
DIVALPROEX DR 125 MG CAP SPRNK |
2 |
Generic |
$10.00 | $30.00 | None |
DIVALPROEX SOD DR 125 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SOD DR 250 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
DIVALPROEX SOD DR 500 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
DIVALPROEX SOD ER 500 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT |
2 |
Generic |
$10.00 | $30.00 | None |
DIVIGEL 1 MG GEL PACKET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
2 |
Generic |
$10.00 | $30.00 | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
2 |
Generic |
$10.00 | $30.00 | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
2 |
Generic |
$10.00 | $30.00 | None |
DOLOPHINE HCL 10MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:360 /30Days |
DOLOPHINE HYDROCHLORIDE 5mg 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:180 /30Days |
DONEPEZIL HCL 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | 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 |
$10.00 | $30.00 | None |
DONEPEZIL HCL 5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
DONEPEZIL HCL ODT 10 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DONEPEZIL HCL ODT 5 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR |
2 |
Generic |
$10.00 | $30.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2 |
Generic |
$10.00 | $30.00 | None |
DOVATO 50-300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
DOVONEX CREAM |
5 |
Specialty Tier |
33% | N/A | None |
DOXAZOSIN MESYLATE 1 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DOXAZOSIN MESYLATE 2 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DOXAZOSIN MESYLATE 4 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXAZOSIN MESYLATE 8 MG TAB |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DOXEPIN 10 MG/ML ORAL CONC |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
DOXEPIN 10MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DOXEPIN 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DOXEPIN 75MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | P |
DOXY 100 VIAL |
2 |
Generic |
$10.00 | $30.00 | None |
Doxycycline 75mg/1 |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE HYCLATE 100 MG CAP |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE 100 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE HYCLATE 50 MG CAP |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE MONO 100 MG CAP |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE MONO 100 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE MONO 150 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE MONO 50 MG CAP |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE MONO 50 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
DOXYCYCLINE MONO 75 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
Doxycycline Monohydrate 150 MG Oral Capsule |
2 |
Generic |
$10.00 | $30.00 | None |
DRONABINOL 10 MG CAPSULE [Marinol] |
2 |
Generic |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
2 |
Generic |
$10.00 | $30.00 | P |
DRONABINOL 5 MG CAPSULE [Marinol] |
2 |
Generic |
$10.00 | $30.00 | P |
DROSP-EE-LEVOMEF 3-0.02-0.451 TABLET [Beyaz] |
2 |
Generic |
$10.00 | $30.00 | None |
DROSPIRENONE-EE 3-0.02 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
DROSPIRENONE-EE 3-0.03 MG TAB |
2 |
Generic |
$10.00 | $30.00 | None |
DUAVEE 0.45-20 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |
DULERA INHALATION AEROSOL |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:13 /30Days |
DULERA INHALATION AEROSOL |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:13 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta] |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta] |
2 |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta] |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DUPIXENT 200 MG/1.14 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
DUPIXENT 300 MG/2 ML SAFE SYRG |
5 |
Specialty Tier |
33% | N/A | P |
duramorph 0.5 mg/ml ampule |
2 |
Generic |
$10.00 | $30.00 | P |
duramorph 1 mg/ml ampule |
2 |
Generic |
$10.00 | $30.00 | P |
DUREZOL 0.05% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
DUTASTERIDE 0.5 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
DYAZIDE 37.5-25 CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | None |