2020 Medicare Part D Plan Formulary Information |
Blue Shield 65 Plus (HMO) (H0504-026-0)
Benefit Details
|
The Blue Shield 65 Plus (HMO) (H0504-026-0) Formulary Drugs Starting with the Letter D in Riverside County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $0.00 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 |
DALFAMPRIDINE ER 10 MG TABLET 12H [Ampyra] |
3 |
Tier 3 |
$40.00 | $100.00 | P Q:2 /1Days |
DALIRESP 250 MCG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:28 /180Days |
DALIRESP 500 MCG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:1 /1Days |
DANAZOL 100 MG CAPSULE [Danocrine] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DANAZOL 50MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DANTROLENE SODIUM 100MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DAPSONE 100 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE 25 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DAPTACEL DTAP VACCINE VIAL |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DAPTOMYCIN 350 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
33% | N/A | None |
DAPTOMYCIN 500 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
33% | N/A | None |
DAURISMO 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
DAURISMO 25 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:3 /1Days |
DEBLITANE 0.35 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEFERASIROX 125 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
33% | N/A | None |
DEFERASIROX 180 MG TABLET [Jadenu] |
5 |
Tier 5 |
33% | N/A | None |
DEFERASIROX 250 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
33% | N/A | None |
DEFERASIROX 360 MG TABLET [Jadenu] |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEFERASIROX 500 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
33% | N/A | None |
DEFERASIROX 90 MG TABLET [Jadenu] |
5 |
Tier 5 |
33% | N/A | None |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Tier 5 |
33% | N/A | Q:1 /1Days |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Tier 5 |
33% | N/A | None |
DENAVIR 1% CREAM (g) |
5 |
Tier 5 |
33% | N/A | P Q:5 /30Days |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DERMOTIC OIL 0.01% EAR DROPS |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DESCOVY 200-25 MG TABLET |
5 |
Tier 5 |
33% | N/A | Q:1 /1Days |
DESIPRAMINE 10 MG TABLET [Norpramin] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DESIPRAMINE 100 MG TABLET [Norpramin] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 150 MG TABLET [Norpramin] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DESIPRAMINE 25 MG TABLET [Norpramin] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DESIPRAMINE 50 MG TABLET [Norpramin] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DESIPRAMINE 75 MG TABLET [Norpramin] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DESMOPRESSIN ACETATE 0.1 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DESOGEST-ETH ESTRA 0.15-0.03MG TABLET [Solia] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Desonide 0.0005 MG/MG Topical Ointment |
4 |
Tier 4 |
$95.00 | $237.50 | S |
DESONIDE 0.05% CREAM (g) [Tridesilon] |
4 |
Tier 4 |
$95.00 | $237.50 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOXIMETASONE 0.25% CREAM |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DESOXIMETASONE 0.25% OINTMENT [Topicort] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DESVENLAFAXINE ER 100 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | S Q:1 /1Days |
DESVENLAFAXINE ER 50 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | S Q:1 /1Days |
DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq] |
3 |
Tier 3 |
$40.00 | $100.00 | Q:4 /1Days |
DESVENLAFAXINE SUC ER 25 MG TABLET ER 24H [Pristiq] |
3 |
Tier 3 |
$40.00 | $100.00 | Q:1 /1Days |
Desvenlafaxine Succinate ER 50 mg tablet [Pristiq] |
3 |
Tier 3 |
$40.00 | $100.00 | Q:1 /1Days |
DEXAMETHASONE 0.1% EYE DROP |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 0.5MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 0.75MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 1.5MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 1MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 2MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 4MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXAMETHASONE 6MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
3 |
Tier 3 |
$40.00 | $100.00 | S Q:1 /1Days |
DEXILANT DR 60 MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | S Q:1 /1Days |
DEXMETHYLPHENIDATE 10 MG TABLET [Focalin] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /1Days |
DEXMETHYLPHENIDATE 2.5 MG TABLET [Focalin] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /1Days |
DEXMETHYLPHENIDATE 5 MG TABLET [Focalin] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /1Days |
DEXTROAMP-AMPHET ER 10 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 15 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
DEXTROAMP-AMPHET ER 20 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
DEXTROAMP-AMPHET ER 25 MG CAPSULE ER 24H [Mydayis] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
DEXTROAMP-AMPHET ER 30 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
DEXTROAMP-AMPHET ER 5 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
DEXTROAMP-AMPHETAMIN 20 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | Q:3 /1Days |
DEXTROAMP-AMPHETAMIN 30 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /1Days |
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $15.00 | Q:4 /1Days |
DEXTROSE 10%-1/4NS IV TUBEX |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 10%-WATER IV SOLUTION DEHP FR BG |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE 5%-0.2% NACL IV SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE 5%-0.45% NACL IV SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE 5%-0.9% NACL IV SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE 5%-1/4NS IV SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE 5%-WATER IV SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:20 /30Days |
DIAZEPAM 10 MG TABLET [Valium] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:6 /1Days |
DIAZEPAM 2 MG TABLET [Valium] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:30 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:5 /30Days |
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:40 /30Days |
DIAZEPAM 5 MG TABLET [Valium] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:12 /1Days |
DIAZEPAM 5 MG/5 ML SOLUTION |
2 |
Tier 2 |
$10.00 | $15.00 | Q:60 /1Days |
DIAZEPAM 5 MG/ML ORAL CONC |
2 |
Tier 2 |
$10.00 | $15.00 | Q:12 /1Days |
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DICLOFENAC 0.1% EYE DROPS [Voltaren] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DICLOFENAC POT 50 MG TABLET [Cataflam] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DICLOFENAC SOD EC 25 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DICLOFENAC SOD EC 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DICLOFENAC SOD EC 75 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | 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 |
Tier 2 |
$10.00 | $15.00 | None |
Diclofenac Sodium 1% gel |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Diclofenac Sodium 3% gel |
5 |
Tier 5 |
33% | N/A | P Q:300 /365Days |
DICLOXACILLIN 250MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DICLOXACILLIN SODIUM 500MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DICYCLOMINE 10 MG CAPSULE [Bentyl] |
2 |
Tier 2 |
$10.00 | $15.00 | P |
DICYCLOMINE 20 MG TABLET [Bentyl] |
2 |
Tier 2 |
$10.00 | $15.00 | P |
DIDANOSINE DR 250 MG CAPSULE [Videx EC] |
3 |
Tier 3 |
$40.00 | $100.00 | Q:1 /1Days |
DIDANOSINE DR 400 MG CAPSULE [Videx EC] |
3 |
Tier 3 |
$40.00 | $100.00 | Q:1 /1Days |
DIFLUNISAL 500 MG TABLET [Dolobid] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DIGITEK 125 MCG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGITEK 250 MCG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIGOX 125 MCG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIGOX 250 MCG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIGOXIN 0.25 MG TABLET [Lanoxin] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIGOXIN 125 MCG TABLET [Lanoxin] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
5 |
Tier 5 |
33% | N/A | P Q:8 /30Days |
DILT XR 120 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILT XR 180 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILT XR 240 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 90 MG TABLET [Cardizem] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIPENTUM 250 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | S |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
2 |
Tier 2 |
$10.00 | $15.00 | P |
DIPHENOXYLATE/ATROPINE LIQ |
2 |
Tier 2 |
$10.00 | $15.00 | P |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DIPYRIDAMOLE 25 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | P |
DIPYRIDAMOLE 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | P |
DIPYRIDAMOLE 75 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | P |
DISOPYRAMIDE 100 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DISULFIRAM 250 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DISULFIRAM 500 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DIVALPROEX DR 125 MG CAPSULE SPRNK |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIVALPROEX SOD DR 125 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIVALPROEX SOD DR 250 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIVALPROEX SOD DR 500 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIVALPROEX SOD ER 250 MG TABLET ER 24H [Depakote ER] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DONEPEZIL HCL 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
DONEPEZIL HCL 23 MG TABLET [Aricept] |
4 |
Tier 4 |
$95.00 | $237.50 | S Q:1 /1Days |
DONEPEZIL HCL 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
DONEPEZIL HCL ODT 10 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DONEPEZIL HCL ODT 5 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOTTI 0.025 MG PATCH TDSW [Vivelle-Dot] |
2 |
Tier 2 |
$10.00 | $15.00 | P Q:16 /28Days |
DOTTI 0.0375 MG PATCH TDSW [Vivelle-Dot] |
2 |
Tier 2 |
$10.00 | $15.00 | P Q:16 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOTTI 0.05 MG PATCH TDSW [Vivelle-Dot] |
2 |
Tier 2 |
$10.00 | $15.00 | P Q:16 /28Days |
DOTTI 0.075 MG PATCH TDSW [Vivelle-Dot] |
2 |
Tier 2 |
$10.00 | $15.00 | P Q:16 /28Days |
DOTTI 0.1 MG PATCH TDSW [Vivelle-Dot] |
2 |
Tier 2 |
$10.00 | $15.00 | P Q:16 /28Days |
DOVATO 50-300 MG TABLET |
5 |
Tier 5 |
33% | N/A | Q:1 /1Days |
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXEPIN 10 MG/ML ORAL CONC |
3 |
Tier 3 |
$40.00 | $100.00 | P |
DOXEPIN 10MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | P |
DOXEPIN 50 MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 75MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
3 |
Tier 3 |
$40.00 | $100.00 | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
3 |
Tier 3 |
$40.00 | $100.00 | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
3 |
Tier 3 |
$40.00 | $100.00 | P |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
4 |
Tier 4 |
$95.00 | $237.50 | P |
Doxercalciferol 1 mcg capsule [HECTOROL] |
4 |
Tier 4 |
$95.00 | $237.50 | P |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
4 |
Tier 4 |
$95.00 | $237.50 | P |
DOXY 100 VIAL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
DOXYCYCLINE HYCLATE 100 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE 50 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXYCYCLINE MONO 100 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXYCYCLINE MONO 100 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DOXYCYCLINE MONO 50 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DRIZALMA SPRINKLE DR 20 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:3 /1Days |
DRIZALMA SPRINKLE DR 30 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:3 /1Days |
DRIZALMA SPRINKLE DR 40 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:2 /1Days |
DRIZALMA SPRINKLE DR 60 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:2 /1Days |
DRONABINOL 10 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:6 /1Days |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:6 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL 5 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:6 /1Days |
DROSPIRENONE-EE 3-0.02 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DROSPIRENONE-EE 3-0.03 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
DROXIA 200MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DROXIA 300MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DROXIA 400MG CAPSULE |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:3 /1Days |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:3 /1Days |
DULOXETINE HCL DR 40 MG CAPSULE [Irenka] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /1Days |
DUOBRII 0.01%-0.045% LOTION |
5 |
Tier 5 |
33% | N/A | P Q:200 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
duramorph 0.5 mg/ml ampule |
4 |
Tier 4 |
$95.00 | $237.50 | P |
duramorph 1 mg/ml ampule |
4 |
Tier 4 |
$95.00 | $237.50 | P |
DUREZOL 0.05% EYE DROPS |
3 |
Tier 3 |
$40.00 | $100.00 | None |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
3 |
Tier 3 |
$40.00 | $100.00 | Q:1 /1Days |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 CPMP 24HR [Jalyn] |
4 |
Tier 4 |
$95.00 | $237.50 | P Q:1 /1Days |