Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Express Scripts Medicare - Choice (PDP) (S5660-182-0)
Tier 1 (247)
Tier 2 (1376)
Tier 3 (616)
Tier 4 (657)
Tier 5 (468)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Choice (PDP) (S5660-182-0)
Benefit Details           
The Express Scripts Medicare - Choice (PDP) (S5660-182-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $87.10 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   4 Non-Preferred Drug 48%N/ANone
D-AMPHETAMINE ER 15 MG CAPSULE   4 Non-Preferred Drug 48%N/ANone
D-AMPHETAMINE ER 5 MG CAPSULE   4 Non-Preferred Drug 48%N/ANone
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN   2* Generic $7.00$4.00None
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN   2* Generic $7.00$4.00None
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 26%N/AP Q:60
/30Days
DALIRESP 250 MCG TABLET   4 Non-Preferred Drug 48%N/AP
DALIRESP 500 MCG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
DANAZOL 100 MG CAPSULE   4 Non-Preferred Drug 48%N/ANone
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 48%N/ANone
DANTROLENE SODIUM 100MG CAPSULE   2* Generic $7.00$4.00None
DANTROLENE SODIUM 25MG CAPSULE   2* Generic $7.00$4.00None
DANTROLENE SODIUM 50MG CAPSULE   2* Generic $7.00$4.00None
DAPSONE 25 MG TABLET   3 Preferred Brand $42.00$126.00None
DAPSONE 5% GEL   3 Preferred Brand $42.00$126.00None
DAPSONE TABLETS 100MG 30 BLPK   3 Preferred Brand $42.00$126.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand $42.00$126.00None
DAPTOMYCIN 350 MG VIAL [Cubicin RF]   3 Preferred Brand $42.00$126.00None
DAPTOMYCIN 500 MG VIAL [Cubicin]   5 Specialty Tier 26%N/ANone
DARAPRIM 25 MG TABLET   5 Specialty Tier 26%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DAURISMO 100 MG TABLET   4 Non-Preferred Drug 48%N/AP
DAURISMO 25 MG TABLET   4 Non-Preferred Drug 48%N/AP
DDAVP 10 MCG/0.1 ML SOLUTION   3 Preferred Brand $42.00$126.00None
DEBLITANE 0.35 MG TABLET   2* Generic $7.00$4.00None
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 26%N/AP
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 26%N/AP
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 26%N/AP
DELSTRIGO 100-300-300 MG TABLET   4 Non-Preferred Drug 48%N/ANone
Delyla-28 tablet   2* Generic $7.00$4.00None
DELZICOL DR 400 MG CAPSULE   4 Non-Preferred Drug 48%N/ANone
DEMECLOCYCLINE 150 MG TABLET   4 Non-Preferred Drug 48%N/ANone
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 48%N/ANone
DEMSER CAPSULES 250MG (100 CT)   4 Non-Preferred Drug 48%N/AP
DENAVIR 1% CREAM (g)   3 Preferred Brand $42.00$126.00None
DEPEN 250MG TITRATAB   5 Specialty Tier 26%N/ANone
DESCOVY 200-25 MG TABLET   5 Specialty Tier 26%N/AQ:30
/30Days
DESIPRAMINE 10 MG TABLET [Norpramin]   2* Generic $7.00$4.00None
DESIPRAMINE 100 MG TABLET [Norpramin]   2* Generic $7.00$4.00None
DESIPRAMINE 150 MG TABLET [Norpramin]   2* Generic $7.00$4.00None
DESIPRAMINE 25 MG TABLET [Norpramin]   2* Generic $7.00$4.00None
DESIPRAMINE 50 MG TABLET [Norpramin]   2* Generic $7.00$4.00None
DESIPRAMINE 75 MG TABLET [Norpramin]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESLORATADINE 2.5 MG ODDT   2* Generic $7.00$4.00Q:30
/30Days
DESLORATADINE 5 MG ODDT   2* Generic $7.00$4.00Q:30
/30Days
DESLORATADINE 5 MG TABLET   2* Generic $7.00$4.00Q:30
/30Days
DESMOPRESSIN ACETATE 0.1 MG TB   2* Generic $7.00$4.00None
DESMOPRESSIN ACETATE 0.2 MG TB   2* Generic $7.00$4.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   3 Preferred Brand $42.00$126.00None
DESOGESTR-ETH ESTRAD   2* Generic $7.00$4.00None
Desonide 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 48%N/ANone
DESONIDE 0.05% CREAM   4 Non-Preferred Drug 48%N/ANone
DESONIDE 0.05% LOTION   4 Non-Preferred Drug 48%N/ANone
Desoximetasone 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESOXIMETASONE 0.25% CREAM   4 Non-Preferred Drug 48%N/ANone
DESOXIMETASONE 0.25% OINTMENT   4 Non-Preferred Drug 48%N/ANone
DESOXIMETASONE 0.25% SPRAY [Topicort]   4 Non-Preferred Drug 48%N/ANone
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 48%N/ANone
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 48%N/ANone
Desvenlafaxine Succinate ER 100 mg [Pristiq]   3 Preferred Brand $42.00$126.00Q:30
/30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   3 Preferred Brand $42.00$126.00Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   3 Preferred Brand $42.00$126.00Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   2* Generic $7.00$4.00None
DEXAMETHASONE 0.5MG TABLET   2* Generic $7.00$4.00None
DEXAMETHASONE 0.5MG/0.5ML DROP   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 0.5MG/5ML ELX   2* Generic $7.00$4.00None
DEXAMETHASONE 0.75MG TABLET   2* Generic $7.00$4.00None
DEXAMETHASONE 1.5MG TABLET   2* Generic $7.00$4.00None
DEXAMETHASONE 10 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2* Generic $7.00$4.00None
DEXAMETHASONE 13 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2* Generic $7.00$4.00None
DEXAMETHASONE 1MG TABLET   2* Generic $7.00$4.00None
DEXAMETHASONE 2MG TABLET   2* Generic $7.00$4.00None
DEXAMETHASONE 4MG TABLET   2* Generic $7.00$4.00None
DEXAMETHASONE 6 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2* Generic $7.00$4.00None
DEXAMETHASONE 6MG TABLET   2* Generic $7.00$4.00None
DEXCHLORPHENIRAMINE 2 MG/5 ML SYRUP [RyClora]   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXILANT CAPSULES DELAYED RELEASE 30 MG   4 Non-Preferred Drug 48%N/AQ:30
/30Days
DEXILANT DR 60 MG CAPSULE   4 Non-Preferred Drug 48%N/AQ:30
/30Days
DEXTROAMP-AMPHET ER 10 MG CAP   2* Generic $7.00$4.00Q:30
/30Days
DEXTROAMP-AMPHET ER 15 MG CAP   2* Generic $7.00$4.00Q:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAP   2* Generic $7.00$4.00Q:60
/30Days
DEXTROAMP-AMPHET ER 25 MG CAP   2* Generic $7.00$4.00Q:60
/30Days
DEXTROAMP-AMPHET ER 30 MG CAP   2* Generic $7.00$4.00Q:60
/30Days
DEXTROAMP-AMPHET ER 5 MG CAP   2* Generic $7.00$4.00Q:60
/30Days
DEXTROAMPHETAMINE 10 MG TAB   2* Generic $7.00$4.00None
DEXTROAMPHETAMINE 5 MG TAB   2* Generic $7.00$4.00None
DEXTROSE 10%-1/4NS IV TUBEX   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Dextrose 10%-water iv solution   2* Generic $7.00$4.00None
DEXTROSE 2.5%-1/2NS IV SOLUTION   2* Generic $7.00$4.00None
DEXTROSE 5%-0.45% NACL IV SOLN   2* Generic $7.00$4.00None
DEXTROSE 5%-0.9% NACL IV SOLN   2* Generic $7.00$4.00None
DEXTROSE 5%-1/4NS IV SOLUTION   2* Generic $7.00$4.00None
DEXTROSE 5%-WATER IV SOLN   2* Generic $7.00$4.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION   2* Generic $7.00$4.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   2* Generic $7.00$4.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   2* Generic $7.00$4.00None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 48%N/ANone
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 48%N/ANone
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 48%N/ANone
DIAZEPAM 10 MG TABLET [Valium]   2* Generic $7.00$4.00P Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   2* Generic $7.00$4.00P Q:120
/30Days
DIAZEPAM 5 MG TABLET [Valium]   2* Generic $7.00$4.00P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   2* Generic $7.00$4.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2* Generic $7.00$4.00P Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2* Generic $7.00$4.00None
DICLOFENAC POT 50 MG TABLET   2* Generic $7.00$4.00None
DICLOFENAC SOD EC 25 MG TAB   2* Generic $7.00$4.00None
DICLOFENAC SOD EC 50 MG TAB   2* Generic $7.00$4.00None
DICLOFENAC SOD EC 75 MG TAB   2* Generic $7.00$4.00None
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 $7.00$4.00None
Diclofenac sodium 1.5% soln   2* Generic $7.00$4.00Q:300
/28Days
Diclofenac Sodium 1% gel   2* Generic $7.00$4.00Q:1000
/28Days
Diclofenac Sodium 3% gel   5 Specialty Tier 26%N/AP Q:100
/28Days
DICLOXACILLIN 250MG CAPSULE   2* Generic $7.00$4.00None
DICLOXACILLIN SODIUM 500MG CAP   2* Generic $7.00$4.00None
DICYCLOMINE 10 MG CAPSULE   2* Generic $7.00$4.00None
DICYCLOMINE 20 MG TABLET   2* Generic $7.00$4.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   2* Generic $7.00$4.00None
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   3 Preferred Brand $42.00$126.00Q:30
/30Days
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   3 Preferred Brand $42.00$126.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   3 Preferred Brand $42.00$126.00Q:30
/30Days
DIFLORASONE 0.05% CREAM   4 Non-Preferred Drug 48%N/ANone
DIFLORASONE 0.05% OINTMENT   4 Non-Preferred Drug 48%N/ANone
DIFLUNISAL 500 MG TABLET   2* Generic $7.00$4.00None
DIGITEK 125 MCG TABLET   2* Generic $7.00$4.00Q:30
/30Days
DIGITEK 250 MCG TABLET   2* Generic $7.00$4.00None
DIGOX 125 MCG TABLET   2* Generic $7.00$4.00Q:30
/30Days
DIGOX 250 MCG TABLET   2* Generic $7.00$4.00None
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   2* Generic $7.00$4.00None
DIGOXIN 125 MCG TABLET [Lanoxin]   2* Generic $7.00$4.00Q:30
/30Days
DIGOXIN 250 MCG TABLET [Lanoxin]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 48%N/ANone
DILT XR 120 MG CAPSULE   2* Generic $7.00$4.00None
DILT XR 180 MG CAPSULE   2* Generic $7.00$4.00None
DILT XR 240 MG CAPSULE   2* Generic $7.00$4.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2* Generic $7.00$4.00None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand $42.00$126.00None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   3 Preferred Brand $42.00$126.00None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   3 Preferred Brand $42.00$126.00None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   2* Generic $7.00$4.00None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   3 Preferred Brand $42.00$126.00None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   2* Generic $7.00$4.00None
DILTIAZEM 24HR ER 360 MG CAP [Tiazac]   3 Preferred Brand $42.00$126.00None
DILTIAZEM 24HR ER 420 MG CAP [Tiazac]   3 Preferred Brand $42.00$126.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2* Generic $7.00$4.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2* Generic $7.00$4.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2* Generic $7.00$4.00None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $42.00$126.00None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $42.00$126.00None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $42.00$126.00None
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand $42.00$126.00None
DIPYRIDAMOLE 25 MG TABLET   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIPYRIDAMOLE 50 MG TABLET   2* Generic $7.00$4.00None
DIPYRIDAMOLE 75 MG TABLET   2* Generic $7.00$4.00None
DISULFIRAM 250 MG TABLET   2* Generic $7.00$4.00None
DISULFIRAM 500 MG TABLET   2* Generic $7.00$4.00None
DIVALPROEX DR 125 MG CAP SPRNK   4 Non-Preferred Drug 48%N/ANone
DIVALPROEX SOD DR 125 MG TAB   1* Preferred Generic $2.00$0.00None
DIVALPROEX SOD DR 250 MG TAB   1* Preferred Generic $2.00$0.00None
DIVALPROEX SOD DR 500 MG TAB   1* Preferred Generic $2.00$0.00None
DIVALPROEX SOD ER 500 MG TAB   4 Non-Preferred Drug 48%N/ANone
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   4 Non-Preferred Drug 48%N/ANone
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   3 Preferred Brand $42.00$126.00None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   3 Preferred Brand $42.00$126.00None
DONEPEZIL HCL 10 MG TABLET   2* Generic $7.00$4.00Q:69
/30Days
DONEPEZIL HCL 5 MG TABLET   2* Generic $7.00$4.00Q:30
/30Days
DONEPEZIL HCL ODT 10 MG TABLET   2* Generic $7.00$4.00Q:69
/30Days
DONEPEZIL HCL ODT 5 MG TABLET   2* Generic $7.00$4.00Q:30
/30Days
DOPTELET 20 MG TABLET   5 Specialty Tier 26%N/AP
DOPTELET 20 MG TABLET   5 Specialty Tier 26%N/AP
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2* Generic $7.00$4.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   2* Generic $7.00$4.00None
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF]   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOVATO 50-300 MG TABLET   5 Specialty Tier 26%N/ANone
DOXAZOSIN MESYLATE 1 MG TAB   1* Preferred Generic $2.00$0.00Q:30
/30Days
DOXAZOSIN MESYLATE 2 MG TAB   1* Preferred Generic $2.00$0.00Q:30
/30Days
DOXAZOSIN MESYLATE 4 MG TAB   1* Preferred Generic $2.00$0.00Q:30
/30Days
DOXAZOSIN MESYLATE 8 MG TAB   1* Preferred Generic $2.00$0.00Q:60
/30Days
DOXEPIN 10 MG/ML ORAL CONC   4 Non-Preferred Drug 48%N/AP
DOXEPIN 10MG CAPSULE   4 Non-Preferred Drug 48%N/AP
DOXEPIN 5% CREAM (g) [Zonalon]   4 Non-Preferred Drug 48%N/AQ:45
/30Days
DOXEPIN 50 MG CAPSULE   4 Non-Preferred Drug 48%N/AP
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 48%N/AP
DOXEPIN HCL 25MG CAPSULE (100 CT)   4 Non-Preferred Drug 48%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 48%N/AP
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   4 Non-Preferred Drug 48%N/AP
Doxercalciferol 0.5 mcg capsule [HECTOROL]   4 Non-Preferred Drug 48%N/ANone
Doxercalciferol 1 mcg capsule [HECTOROL]   5 Specialty Tier 26%N/ANone
Doxercalciferol 2.5 mcg capsule [HECTOROL]   5 Specialty Tier 26%N/ANone
DOXY 100 VIAL   4 Non-Preferred Drug 48%N/ANone
doxycycline 25 mg/5 ml susp   2* Generic $7.00$4.00None
Doxycycline 75mg/1   4 Non-Preferred Drug 48%N/ANone
DOXYCYCLINE HYCLATE 100 MG CAP   2* Generic $7.00$4.00None
DOXYCYCLINE HYCLATE 100 MG TAB   2* Generic $7.00$4.00None
DOXYCYCLINE HYCLATE 150 MG TAB   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   2* Generic $7.00$4.00None
DOXYCYCLINE HYCLATE 50 MG CAP   2* Generic $7.00$4.00None
DOXYCYCLINE HYCLATE 75 MG TAB   2* Generic $7.00$4.00None
DOXYCYCLINE MONO 100 MG CAP   4 Non-Preferred Drug 48%N/ANone
DOXYCYCLINE MONO 100 MG TABLET   2* Generic $7.00$4.00None
DOXYCYCLINE MONO 150 MG TABLET   2* Generic $7.00$4.00None
DOXYCYCLINE MONO 50 MG CAP   4 Non-Preferred Drug 48%N/ANone
DOXYCYCLINE MONO 50 MG TABLET   2* Generic $7.00$4.00None
DOXYCYCLINE MONO 75 MG TABLET   2* Generic $7.00$4.00None
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
DROSP-EE-LEVOMEF 3-0.02-0.451 TABLET [Beyaz]   2* Generic $7.00$4.00None
DROSPIRENONE-EE 3-0.02 MG TAB   2* Generic $7.00$4.00None
DROSPIRENONE-EE 3-0.03 MG TAB   2* Generic $7.00$4.00None
DROXIA 200MG CAPSULE   3 Preferred Brand $42.00$126.00None
DROXIA 300MG CAPSULE   3 Preferred Brand $42.00$126.00None
DROXIA 400MG CAPSULE   3 Preferred Brand $42.00$126.00None
DULERA INHALATION AEROSOL   3 Preferred Brand $42.00$126.00Q:13
/30Days
DULERA INHALATION AEROSOL   3 Preferred Brand $42.00$126.00Q:13
/30Days
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta]   2* Generic $7.00$4.00Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta]   2* Generic $7.00$4.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DULOXETINE HCL DR 40 MG CAPSULE DR [Irenka]   2* Generic $7.00$4.00Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta]   2* Generic $7.00$4.00Q:60
/30Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 26%N/AP
DUPIXENT 300 MG/2 ML SAFE SYRG   5 Specialty Tier 26%N/AP
duramorph 0.5 mg/ml ampule   2* Generic $7.00$4.00Q:4000
/30Days
duramorph 1 mg/ml ampule   2* Generic $7.00$4.00Q:2000
/30Days
DUTASTERIDE 0.5 MG CAPSULE   3 Preferred Brand $42.00$126.00None
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn]   3 Preferred Brand $42.00$126.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Express Scripts Medicare - Choice (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.