2020 Medicare Part D Plan Formulary Information |
Allwell Medicare (HMO) (H9630-001-0)
Benefit Details
|
The Allwell Medicare (HMO) (H9630-001-0) Formulary Drugs Starting with the Letter D in Newton County, AR: CMS MA Region 15 which includes: AR Plan Monthly Premium: $0.00 Deductible: $250 |
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 |
$100.00 | $300.00 | None |
D-AMPHETAMINE ER 15 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
D-AMPHETAMINE ER 5 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DALFAMPRIDINE ER 10 MG TABLET 12H [Ampyra] |
5 |
Tier 5 |
28% | N/A | P |
DALIRESP 250 MCG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
DALIRESP 500 MCG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
DALVANCE 500 MG VIAL |
5 |
Tier 5 |
28% | N/A | None |
DANAZOL 100 MG CAPSULE [Danocrine] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DANAZOL 50MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTROLENE SODIUM 100MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DANTROLENE SODIUM 25MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DAPSONE 100 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DAPSONE 25 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DAPTACEL DTAP VACCINE VIAL |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DAPTOMYCIN 500 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
28% | N/A | None |
DARIFENACIN ER 15 MG TABLET 24H [Enablex] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DARIFENACIN ER 7.5 MG TABLET 24H [Enablex] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DAURISMO 100 MG TABLET |
5 |
Tier 5 |
28% | N/A | P |
DAURISMO 25 MG TABLET |
5 |
Tier 5 |
28% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DAYTRANA PATCH 1.1 MG/HR |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DAYTRANA PATCH 1.6 MG/HR |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DAYTRANA PATCH 2.2 MG/HR |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DAYTRANA PATCH 3.3 MG/HR |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEBLITANE 0.35 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEFERASIROX 125 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
28% | N/A | None |
DEFERASIROX 180 MG TABLET [Jadenu] |
5 |
Tier 5 |
28% | N/A | None |
DEFERASIROX 250 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
28% | N/A | None |
DEFERASIROX 360 MG TABLET [Jadenu] |
5 |
Tier 5 |
28% | N/A | None |
DEFERASIROX 500 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
28% | N/A | None |
DEFERASIROX 90 MG TABLET [Jadenu] |
5 |
Tier 5 |
28% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Tier 5 |
28% | N/A | None |
DEMECLOCYCLINE 150 MG TABLET [Declomycin] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEMECLOCYCLINE 300 MG TABLET [Declomycin] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEMSER CAPSULES 250MG (100 CT) |
5 |
Tier 5 |
28% | N/A | None |
DENAVIR 1% CREAM (g) |
5 |
Tier 5 |
28% | N/A | None |
DEPAKOTE 125MG SPRINKLE CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEPAKOTE 125MG TABLET EC |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEPAKOTE DR 250 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEPAKOTE DR 500 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEPAKOTE ER 250MG TABLET SA |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEPAKOTE ER 500MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEPO-PROVERA 400MG/ML VIAL |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DESCOVY 200-25 MG TABLET |
5 |
Tier 5 |
28% | N/A | None |
DESIPRAMINE 10 MG TABLET [Norpramin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESIPRAMINE 100 MG TABLET [Norpramin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESIPRAMINE 150 MG TABLET [Norpramin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESIPRAMINE 25 MG TABLET [Norpramin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESIPRAMINE 50 MG TABLET [Norpramin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESIPRAMINE 75 MG TABLET [Norpramin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESLORATADINE 5 MG ODDT |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DESLORATADINE 5 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESMOPRESSIN ACETATE 0.1 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DESOGEST-ETH ESTRA 0.15-0.03MG TABLET [Solia] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Desonide 0.0005 MG/MG Topical Ointment |
4 |
Tier 4 |
$100.00 | $300.00 | Q:2 /1Days |
DESONIDE 0.05% CREAM (g) [Tridesilon] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:2 /1Days |
DESONIDE 0.05% LOTION [LoKara] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:4 /1Days |
Desoximetasone 0.0005 MG/MG Topical Ointment |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DESOXIMETASONE 0.25% CREAM |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESOXIMETASONE 0.25% OINTMENT [Topicort] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOXIMETASONE 0.25% SPRAY [Topicort] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DESVENLAFAXINE ER 100 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | S |
DESVENLAFAXINE ER 50 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | S |
DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DESVENLAFAXINE SUC ER 25 MG TABLET ER 24H [Pristiq] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Desvenlafaxine Succinate ER 50 mg tablet [Pristiq] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXAMETHASONE 0.1% EYE DROP |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXAMETHASONE 0.5MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXAMETHASONE 0.5MG/5ML ELX |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DEXAMETHASONE 0.75MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 1.5MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXAMETHASONE 10 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXAMETHASONE 13 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXAMETHASONE 1MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXAMETHASONE 2MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXAMETHASONE 4MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXAMETHASONE 6 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXAMETHASONE 6MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DEXILANT CAPSULES DELAYED RELEASE 30 MG |
3* |
Tier 3 |
$47.00 | $141.00 | S |
DEXILANT DR 60 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | S |
DEXMETHYLPHENIDATE 10 MG TABLET [Focalin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE 2.5 MG TABLET [Focalin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DEXMETHYLPHENIDATE 5 MG TABLET [Focalin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DEXMETHYLPHENIDATE ER 10 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 15 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 20 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 25 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 30 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 35 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 40 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXMETHYLPHENIDATE ER 5 MG CAPSULE CPBP 50-50 [Focalin XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMP-AMPHET ER 10 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
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 |
$100.00 | $300.00 | None |
DEXTROAMP-AMPHET ER 20 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMP-AMPHET ER 25 MG CAPSULE ER 24H [Mydayis] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMP-AMPHET ER 30 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMP-AMPHET ER 5 MG CAPSULE ER 24H [Adderall XR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMP-AMPHETAMIN 20 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXTROAMP-AMPHETAMIN 30 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXTROSE 10%-WATER IV SOLUTION DEHP FR BG |
2* |
Tier 2 |
$8.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXTROSE 5%-0.2% NACL IV SOLUTION |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DEXTROSE 5%-0.45% NACL IV SOLUTION |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXTROSE 5%-0.9% NACL IV SOLUTION |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DEXTROSE 5%-WATER IV SOLUTION |
2* |
Tier 2 |
$8.00 | $0.00 | P |
DIASTAT 2.5 MG PEDI SYSTEM |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIASTAT ACUDIAL 12.5-15-20 MG |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIASTAT ACUDIAL 5-7.5-10 MG KIT |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIAZEPAM 10 MG TABLET [Valium] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DIAZEPAM 2 MG TABLET [Valium] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
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 |
$100.00 | $300.00 | None |
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIAZEPAM 5 MG TABLET [Valium] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DIAZEPAM 5 MG/5 ML SOLUTION |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DIAZEPAM 5 MG/ML ORAL CONC |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DICLOFENAC 0.1% EYE DROPS [Voltaren] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DICLOFENAC EPOLAMINE 1.3% PATCH TD12 [Licart] |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DICLOFENAC POT 50 MG TABLET [Cataflam] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DICLOFENAC SOD EC 25 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DICLOFENAC SOD EC 50 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | 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 | $0.00 | None |
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Diclofenac sodium 1.5% soln |
4 |
Tier 4 |
$100.00 | $300.00 | Q:15 /1Days |
Diclofenac Sodium 1% gel |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Diclofenac Sodium 3% gel |
4 |
Tier 4 |
$100.00 | $300.00 | P Q:3 /1Days |
DICLOFENAC-MISOPROST 50-200 TABLET IR DR [Arthrotec] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DICLOFENAC-MISOPROST 75-200 TABLET IR DR [Arthrotec] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DICLOXACILLIN 250MG CAPSULE |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DICLOXACILLIN SODIUM 500MG CAPSULE |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DICYCLOMINE 10 MG CAPSULE [Bentyl] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DICYCLOMINE 20 MG TABLET [Bentyl] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIDANOSINE DR 250 MG CAPSULE [Videx EC] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DIDANOSINE DR 400 MG CAPSULE [Videx EC] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Tier 5 |
28% | N/A | None |
DIFLORASONE 0.05% OINTMENT |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIFLUNISAL 500 MG TABLET [Dolobid] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
DIGITEK 125 MCG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIGITEK 250 MCG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIGOX 125 MCG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIGOX 250 MCG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DIGOXIN 0.25 MG TABLET [Lanoxin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGOXIN 125 MCG TABLET [Lanoxin] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
5 |
Tier 5 |
28% | N/A | None |
DILANTIN 50MG INFATAB |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DILANTIN CAPSULES 30 MG ER |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DILANTIN-125 SUS 125/5ML |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DILT XR 120 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILT XR 180 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILT XR 240 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIPENTUM 250 MG CAPSULE |
5 |
Tier 5 |
28% | N/A | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DIPYRIDAMOLE 25 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DIPYRIDAMOLE 50 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DIPYRIDAMOLE 75 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DISOPYRAMIDE 100 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DISULFIRAM 250 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DISULFIRAM 500 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIVALPROEX DR 125 MG CAPSULE SPRNK |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DIVALPROEX SOD DR 125 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DIVALPROEX SOD DR 250 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DIVALPROEX SOD DR 500 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DIVALPROEX SOD ER 250 MG TABLET ER 24H [Depakote ER] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DIVIGEL 1 MG GEL PACKET |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DONEPEZIL HCL 10 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DONEPEZIL HCL 23 MG TABLET [Aricept] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DONEPEZIL HCL 5 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DONEPEZIL HCL ODT 10 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DONEPEZIL HCL ODT 5 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOPTELET 20 MG (30 TABLET PK) |
5 |
Tier 5 |
28% | N/A | P |
DOPTELET 20 MG TABLET |
5 |
Tier 5 |
28% | N/A | P |
DOPTELET 20 MG TABLET |
5 |
Tier 5 |
28% | N/A | P |
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOTTI 0.025 MG PATCH TDSW [Vivelle-Dot] |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOTTI 0.0375 MG PATCH TDSW [Vivelle-Dot] |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOTTI 0.05 MG PATCH TDSW [Vivelle-Dot] |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOTTI 0.075 MG PATCH TDSW [Vivelle-Dot] |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOTTI 0.1 MG PATCH TDSW [Vivelle-Dot] |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOVATO 50-300 MG TABLET |
5 |
Tier 5 |
28% | N/A | None |
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXEPIN 10 MG/ML ORAL CONC |
1* |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN 10MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOXEPIN 5% CREAM (g) [Zonalon] |
4 |
Tier 4 |
$100.00 | $300.00 | P Q:2 /1Days |
DOXEPIN 50 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOXEPIN 75MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOXEPIN HCL 3 MG TABLET [Silenor] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:2 /1Days |
DOXEPIN HCL 6 MG TABLET [Silenor] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
3* |
Tier 3 |
$47.00 | $141.00 | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
3* |
Tier 3 |
$47.00 | $141.00 | P |
Doxercalciferol 0.5 mcg capsule [HECTOROL] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Doxercalciferol 1 mcg capsule [HECTOROL] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Doxercalciferol 2.5 mcg capsule [HECTOROL] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DOXY 100 VIAL |
2* |
Tier 2 |
$8.00 | $0.00 | Q:2 /1Days |
doxycycline 25 mg/5 ml susp |
2* |
Tier 2 |
$8.00 | $0.00 | None |
Doxycycline 75mg/1 |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE HYC DR 100 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DOXYCYCLINE HYC DR 150 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DOXYCYCLINE HYC DR 200 MG TABLET [Doryx] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE HYCLATE 100 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DOXYCYCLINE HYCLATE 50 MG CAPSULE |
3* |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE MONO 100 MG CAPSULE |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE MONO 100 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE MONO 150 MG CAPSULE [Adoxa] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE MONO 150 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE MONO 50 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DOXYCYCLINE MONO 75 MG TABLET |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DRIZALMA SPRINKLE DR 20 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | S |
DRIZALMA SPRINKLE DR 30 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | S |
DRIZALMA SPRINKLE DR 40 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | S |
DRIZALMA SPRINKLE DR 60 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL 10 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DRONABINOL 5 MG CAPSULE [Marinol] |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DROSP-EE-LEVOMEF 3-0.02-0.451 [Beyaz, Safyral] |
2* |
Tier 2 |
$8.00 | $0.00 | None |
DROSPIRENONE-EE 3-0.02 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DROSPIRENONE-EE 3-0.03 MG TABLET |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DROXIA 200MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DROXIA 300MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DROXIA 400MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DUAVEE 0.45-20 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | P |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
DUOPA 4.63 MG-20 MG/ML SUSPENSION |
4 |
Tier 4 |
$100.00 | $300.00 | P |
duramorph 0.5 mg/ml ampule |
3* |
Tier 3 |
$47.00 | $141.00 | None |
duramorph 1 mg/ml ampule |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DUREZOL 0.05% EYE DROPS |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
3* |
Tier 3 |
$47.00 | $141.00 | None |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 CPMP 24HR [Jalyn] |
4 |
Tier 4 |
$100.00 | $300.00 | None |