2020 Medicare Part D Plan Formulary Information |
Network PlatinumSelect (PPO) (H5215-008-0)
Benefit Details
|
The Network PlatinumSelect (PPO) (H5215-008-0) Formulary Drugs Starting with the Letter D in Portage County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $0.00 Deductible: $395 |
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 |
Tier 4 |
$84.00 | $210.00 | None |
D-AMPHETAMINE ER 15 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
D-AMPHETAMINE ER 5 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
D5%-1/2NS-KCL 10 MEQ/L IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
D5%-1/2NS-KCL 30 MEQ/L IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
D5%-1/2NS-KCL 40 MEQ/L IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DALFAMPRIDINE ER 10 MG TABLET 12H [Ampyra] |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
DALIRESP 250 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DALIRESP 500 MCG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DALVANCE 500 MG VIAL |
5 |
Tier 5 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANAZOL 100 MG CAPSULE [Danocrine] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DANAZOL 50MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DANTRIUM 25 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DANTRIUM 50 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DANTROLENE SODIUM 100MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DAPSONE 100 MG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DAPSONE 25 MG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DAPSONE 5% GEL [Aczone] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAPSONE 7.5% GEL W/PUMP [Aczone] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DAPTACEL DTAP VACCINE VIAL |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DAPTOMYCIN 350 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
25% | N/A | None |
DAPTOMYCIN 500 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
25% | N/A | None |
DARAPRIM 25 MG TABLET |
5 |
Tier 5 |
25% | N/A | None |
DARIFENACIN ER 15 MG TABLET 24H [Enablex] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DARIFENACIN ER 7.5 MG TABLET 24H [Enablex] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DAURISMO 100 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:30 /30Days |
DAURISMO 25 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
DAYPRO 600MG CAPLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DAYTRANA PATCH 1.1 MG/HR |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAYTRANA PATCH 1.6 MG/HR |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DAYTRANA PATCH 2.2 MG/HR |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DAYTRANA PATCH 3.3 MG/HR |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DAYVIGO 10 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DAYVIGO 5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DDAVP 0.01% NASAL SPRAY |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DDAVP 0.1 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DDAVP 0.2 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DDAVP 10 MCG/0.1 ML SOLUTION |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEBLITANE 0.35 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEFERASIROX 125 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEFERASIROX 180 MG TABLET [Jadenu] |
5 |
Tier 5 |
25% | N/A | None |
DEFERASIROX 250 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
25% | N/A | None |
DEFERASIROX 360 MG TABLET [Jadenu] |
5 |
Tier 5 |
25% | N/A | None |
DEFERASIROX 500 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
25% | N/A | None |
DEFERASIROX 90 MG TABLET [Jadenu] |
5 |
Tier 5 |
25% | N/A | None |
DELESTROGEN 40 MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DELESTROGEN INJECTION 10MG/5ML VIALMD |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DELESTROGEN INJECTION 20MG/5ML VIALMD |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Tier 5 |
25% | N/A | None |
DELZICOL DR 400 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DEMECLOCYCLINE 150 MG TABLET [Declomycin] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEMECLOCYCLINE 300 MG TABLET [Declomycin] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Tier 5 |
25% | N/A | None |
DENAVIR 1% CREAM (g) |
5 |
Tier 5 |
25% | N/A | Q:5 /30Days |
DEPAKOTE 125MG SPRINKLE CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | S |
DEPAKOTE 125MG TABLET EC |
4 |
Tier 4 |
$84.00 | $210.00 | S |
DEPAKOTE DR 250 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
DEPAKOTE DR 500 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
DEPAKOTE ER 250MG TABLET SA |
4 |
Tier 4 |
$84.00 | $210.00 | S |
DEPAKOTE ER 500MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | S |
DEPEN 250MG TITRATAB |
5 |
Tier 5 |
25% | N/A | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-PROVERA 150 MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DEPO-TESTOSTERONE 100 MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEPO-TESTOSTERONE 200 MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DERMA-SMOOTHE-FS SCALP OIL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DERMOTIC OIL 0.01% EAR DROPS |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESCOVY 200-25 MG TABLET |
5 |
Tier 5 |
25% | N/A | None |
DESIPRAMINE 10 MG TABLET [Norpramin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESIPRAMINE 100 MG TABLET [Norpramin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESIPRAMINE 150 MG TABLET [Norpramin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 25 MG TABLET [Norpramin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESIPRAMINE 50 MG TABLET [Norpramin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESIPRAMINE 75 MG TABLET [Norpramin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESLORATADINE 2.5 MG ODDT |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESLORATADINE 5 MG ODDT |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESLORATADINE 5 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESMOPRESSIN ACETATE 0.1 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESOGEST-ETH ESTRA 0.15-0.03MG TABLET [Solia] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONATE 0.05% GEL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Desonide 0.0005 MG/MG Topical Ointment |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESONIDE 0.05% CREAM (g) [Tridesilon] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESONIDE 0.05% LOTION [LoKara] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DesOwen 0.5mg/g 60 g in 1 TUBE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Desoximetasone 0.0005 MG/MG Topical Ointment |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESOXIMETASONE 0.25% CREAM |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESOXIMETASONE 0.25% OINTMENT [Topicort] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESOXIMETASONE 0.25% SPRAY [Topicort] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOXYN 5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DESVENLAFAXINE ER 100 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESVENLAFAXINE ER 50 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DESVENLAFAXINE SUC ER 25 MG TABLET ER 24H [Pristiq] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Desvenlafaxine Succinate ER 50 mg tablet [Pristiq] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DETROL 1 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DETROL 2 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DETROL LA 2 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DETROL LA 4 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEXABLISS 11 DAY 1.5 MG TABLET DS PK [ZCORT] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.1% EYE DROP |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 0.5MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 0.5MG/0.5ML EYE DROP |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 0.75MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 1.5MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 1MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 2MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 4MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXAMETHASONE 6MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXEDRINE SPANSULE 10 MG CAPSULE ER |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXEDRINE SPANSULE 15 MG CAPSULE ER |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEXEDRINE SPANSULE 5 MG CAPSULE ER |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DEXILANT DR 60 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DEXMETHYLPHENIDATE 10 MG TABLET [Focalin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE 2.5 MG TABLET [Focalin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE 5 MG TABLET [Focalin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE ER 10 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEXMETHYLPHENIDATE ER 15 MG CAPSULE CPBP 50-50 [Focalin XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE ER 20 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEXMETHYLPHENIDATE ER 25 MG CAPSULE CPBP 50-50 [Focalin XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE ER 30 MG CAPSULE CPBP 50-50 [Focalin XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE ER 35 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE ER 40 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXMETHYLPHENIDATE ER 5 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DEXTROAMP-AMPHET ER 10 MG CAPSULE ER 24H [Adderall XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMP-AMPHET ER 15 MG CAPSULE ER 24H [Adderall XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMP-AMPHET ER 20 MG CAPSULE ER 24H [Adderall XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMP-AMPHET ER 25 MG CAPSULE ER 24H [Mydayis] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMP-AMPHET ER 30 MG CAPSULE ER 24H [Adderall XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMP-AMPHET ER 5 MG CAPSULE ER 24H [Adderall XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMP-AMPHETAMIN 20 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHETAMIN 30 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE 5 MG/5 ML SOLUTION [ProCentra] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 10%-1/4NS IV TUBEX |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 10%-WATER IV SOLUTION DEHP FR BG |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 5%-0.2% NACL IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 5%-0.45% NACL IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 5%-0.9% NACL IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 5%-1/4NS IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE 5%-WATER IV SOLUTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIASTAT ACUDIAL 5-7.5-10 MG KIT |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZEPAM 10 MG TABLET [Valium] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZEPAM 2 MG TABLET [Valium] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIAZEPAM 5 MG ORAL TABLET [Valium] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIAZEPAM 5 MG TABLET [Valium] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZEPAM 5 MG/5 ML SOLUTION |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZEPAM 5 MG/ML ORAL CONC |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIBENZYLINE 10 MG CAPSULE |
5 |
Tier 5 |
25% | N/A | None |
DICLOFENAC 0.1% EYE DROPS [Voltaren] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOFENAC EPOLAMINE 1.3% PATCH TD12 [Licart] |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DICLOFENAC POT 50 MG TABLET [Cataflam] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOFENAC SOD EC 25 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOFENAC SOD EC 50 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SOD EC 75 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Diclofenac sodium 1.5% soln |
4 |
Tier 4 |
$84.00 | $210.00 | Q:300 /28Days |
Diclofenac Sodium 1% gel |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Diclofenac Sodium 3% gel |
4 |
Tier 4 |
$84.00 | $210.00 | P Q:100 /30Days |
DICLOFENAC-MISOPROST 50-200 TABLET IR DR [Arthrotec] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOFENAC-MISOPROST 75-200 TABLET IR DR [Arthrotec] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOXACILLIN 250MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICLOXACILLIN SODIUM 500MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DICYCLOMINE 10 MG CAPSULE [Bentyl] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DICYCLOMINE 20 MG TABLET [Bentyl] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE HCL 10MG/5ML SYRUP |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIDANOSINE DR 250 MG CAPSULE [Videx EC] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIDANOSINE DR 400 MG CAPSULE [Videx EC] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIFFERIN 0.1% CREAM |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DIFFERIN 0.3% GEL PUMP |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DIFFERIN LOTION |
4 |
Tier 4 |
$84.00 | $210.00 | P |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Tier 5 |
25% | N/A | P Q:20 /10Days |
DIFLORASONE 0.05% CREAM |
4 |
Tier 4 |
$84.00 | $210.00 | Q:120 /30Days |
DIFLORASONE 0.05% OINTMENT |
4 |
Tier 4 |
$84.00 | $210.00 | Q:120 /30Days |
DIFLUCAN 100MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIFLUCAN 150MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIFLUCAN 200MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIFLUCAN 200MG/5ML SUSPEN |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIFLUCAN 50MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIFLUCAN 50MG/5ML SUSPEN |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIFLUNISAL 500 MG TABLET [Dolobid] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIGITEK 125 MCG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIGITEK 250 MCG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIGOX 125 MCG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIGOX 250 MCG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIGOXIN 0.25 MG TABLET [Lanoxin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGOXIN 125 MCG TABLET [Lanoxin] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
5 |
Tier 5 |
25% | N/A | Q:8 /28Days |
DILANTIN 50MG INFATAB |
3* |
Tier 3 |
$42.00 | $105.00 | S |
DILANTIN CAPSULES 30 MG ER |
3* |
Tier 3 |
$42.00 | $105.00 | S |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
3* |
Tier 3 |
$42.00 | $105.00 | S |
DILANTIN-125 SUS 125/5ML |
3* |
Tier 3 |
$42.00 | $105.00 | S |
DILAUDID 2 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:180 /30Days |
DILAUDID 4 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:180 /30Days |
DILAUDID 5 MG/5 ML ORAL LIQUID |
4 |
Tier 4 |
$84.00 | $210.00 | Q:1500 /30Days |
DILAUDID 8 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:180 /30Days |
DILT XR 120 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILT XR 180 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILT XR 240 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIOVAN 160MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN 320MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN 40MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN 80MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN HCT 160/12.5MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN HCT 160/25MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN HCT 320/12.5MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIOVAN HCT 320/25MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIOVAN HCT 80/12.5MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIPENTUM 250 MG CAPSULE |
5 |
Tier 5 |
25% | N/A | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DIPROLENE 0.05% OINTMENT |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIPYRIDAMOLE 25 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIPYRIDAMOLE 50 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPYRIDAMOLE 75 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DISOPYRAMIDE 100 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DISULFIRAM 250 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DISULFIRAM 500 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DITROPAN XL 10 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DITROPAN XL 5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DIVALPROEX DR 125 MG CAPSULE SPRNK |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIVALPROEX SOD DR 125 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIVALPROEX SOD DR 250 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SOD DR 500 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIVALPROEX SOD ER 250 MG TABLET ER 24H [Depakote ER] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DIVIGEL 1 MG GEL PACKET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOLOPHINE HCL 10MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:120 /30Days |
DOLOPHINE HYDROCHLORIDE 5mg 100 TABLET BOTTLE |
4 |
Tier 4 |
$84.00 | $210.00 | Q:240 /30Days |
DONEPEZIL HCL 10 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
DONEPEZIL HCL 23 MG TABLET [Aricept] |
4 |
Tier 4 |
$84.00 | $210.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DONEPEZIL HCL 5 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
DONEPEZIL HCL ODT 10 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
DONEPEZIL HCL ODT 5 MG TABLET |
1* |
Tier 1 |
$2.00 | $0.00 | None |
DOPTELET 20 MG (30 TABLET PK) |
5 |
Tier 5 |
25% | N/A | P |
DOPTELET 20 MG TABLET |
5 |
Tier 5 |
25% | N/A | P |
DOPTELET 20 MG TABLET |
5 |
Tier 5 |
25% | N/A | P |
DORYX DR 200 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DORYX DR 50 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DORYX MPC DR 120 MG TABLET DR |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOTTI 0.025 MG PATCH TDSW [Vivelle-Dot] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOTTI 0.0375 MG PATCH TDSW [Vivelle-Dot] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOTTI 0.05 MG PATCH TDSW [Vivelle-Dot] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOTTI 0.075 MG PATCH TDSW [Vivelle-Dot] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOTTI 0.1 MG PATCH TDSW [Vivelle-Dot] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOVATO 50-300 MG TABLET |
5 |
Tier 5 |
25% | N/A | None |
DOVONEX CREAM |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXEPIN 10 MG/ML ORAL CONC |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN 10MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN 5% CREAM (g) [Zonalon] |
5 |
Tier 5 |
25% | N/A | P |
DOXEPIN 50 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN 75MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN HCL 3 MG TABLET [Silenor] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN HCL 6 MG TABLET [Silenor] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Doxercalciferol 1 mcg capsule [HECTOROL] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXY 100 VIAL |
2* |
Tier 2 |
$8.00 | $20.00 | None |
doxycycline 25 mg/5 ml susp |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Doxycycline 75mg/1 |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DOXYCYCLINE HYC DR 100 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DOXYCYCLINE HYC DR 150 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DOXYCYCLINE HYC DR 200 MG TABLET [Doryx] |
3* |
Tier 3 |
$42.00 | $105.00 | None |
Doxycycline hyc dr 50 MG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DOXYCYCLINE HYC DR 75 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE 100 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 150 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 50 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE HYCLATE 75 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DOXYCYCLINE MONO 100 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE MONO 100 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE MONO 150 MG CAPSULE [Adoxa] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE MONO 150 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE MONO 50 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DOXYCYCLINE MONO 75 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DRIZALMA SPRINKLE DR 20 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DRIZALMA SPRINKLE DR 30 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DRIZALMA SPRINKLE DR 40 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DRIZALMA SPRINKLE DR 60 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DRONABINOL 10 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DRONABINOL 5 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DROSP-EE-LEVOMEF 3-0.02-0.451 [Beyaz, Safyral] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DROSPIRENONE-EE 3-0.02 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DROSPIRENONE-EE 3-0.03 MG TABLET |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DROXIA 200MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DROXIA 300MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DROXIA 400MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DUAKLIR PRESSAIR 400-12MCG INH AER POW BA |
5 |
Tier 5 |
25% | N/A | Q:1 /30Days |
DUAVEE 0.45-20 MG TABLET |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DUETACT 30MG-2MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DUETACT 30MG-4MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | Q:30 /30Days |
DULERA 50 MCG-5 MCG INHALER HFA AEROSOL AD |
3* |
Tier 3 |
$42.00 | $105.00 | Q:13 /30Days |
DULERA INHALATION AEROSOL |
3* |
Tier 3 |
$42.00 | $105.00 | Q:13 /30Days |
DULERA INHALATION AEROSOL |
3* |
Tier 3 |
$42.00 | $105.00 | Q:13 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DULOXETINE HCL DR 40 MG CAPSULE [Irenka] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DUOBRII 0.01%-0.045% LOTION |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DUOPA 4.63 MG-20 MG/ML SUSPENSION |
4 |
Tier 4 |
$84.00 | $210.00 | P |
DUPIXENT 200 MG/1.14 ML SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
DUPIXENT 300 MG/2 ML SAFE SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
DURAGESIC 100 MCG/HR PATCH TD72 |
5 |
Tier 5 |
25% | N/A | Q:10 /30Days |
DURAGESIC 12 MCG/HR PATCH TD72 |
4 |
Tier 4 |
$84.00 | $210.00 | Q:10 /30Days |
DURAGESIC 25 MCG/HR PATCH TD72 |
4 |
Tier 4 |
$84.00 | $210.00 | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DURAGESIC 50 MCG/HR PATCH TD72 |
4 |
Tier 4 |
$84.00 | $210.00 | Q:10 /30Days |
DURAGESIC 75 MCG/HR PATCH TD72 |
5 |
Tier 5 |
25% | N/A | Q:10 /30Days |
duramorph 0.5 mg/ml ampule |
2* |
Tier 2 |
$8.00 | $20.00 | Q:4000 /30Days |
duramorph 1 mg/ml ampule |
2* |
Tier 2 |
$8.00 | $20.00 | Q:2000 /30Days |
DUREZOL 0.05% EYE DROPS |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 CPMP 24HR [Jalyn] |
2* |
Tier 2 |
$8.00 | $20.00 | None |
DUTOPROL 100-12.5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DUTOPROL 25-12.5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DUTOPROL 50-12.5 MG TABLET |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DYANAVEL XR 2.5 MG/ML SUSP |
4 |
Tier 4 |
$84.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DYAZIDE 37.5-25 CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |
DYMISTA NASAL SPRAY |
4 |
Tier 4 |
$84.00 | $210.00 | S Q:23 /30Days |
DYRENIUM 100 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $105.00 | None |
DYRENIUM 50 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $210.00 | None |