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2020 Medicare Part D and Medicare Advantage Plan Formulary Browser

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BlueMedicare Complete Rx (PDP) (S5904-002-0)
Tier 1 (260)
Tier 2 (1751)
Tier 3 (373)
Tier 4 (1018)
Tier 5 (851)
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Uses Step Therapy:
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2020 Medicare Part D Plan Formulary Information
BlueMedicare Complete Rx (PDP) (S5904-002-0)
Benefits & Contact Info           
The BlueMedicare Complete Rx (PDP) (S5904-002-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $167.30 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter D

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
D-AMPHETAMINE ER 10 MG CAPSULE   2 Generic $10.00$30.00Q:120
/30Days
D-AMPHETAMINE ER 15 MG CAPSULE   2 Generic $10.00$30.00Q:120
/30Days
D-AMPHETAMINE ER 5 MG CAPSULE   2 Generic $10.00$30.00Q:90
/30Days
D5%-1/2NS-KCL 10 MEQ/L IV SOLUTION   2 Generic $10.00$30.00None
D5%-1/2NS-KCL 30 MEQ/L IV SOLUTION   2 Generic $10.00$30.00None
D5%-1/2NS-KCL 40 MEQ/L IV SOLUTION   2 Generic $10.00$30.00None
DALFAMPRIDINE ER 10 MG TABLET 12H [Ampyra]   5 Specialty Tier 33%N/AP
DALIRESP 250 MCG TABLET   4 Non-Preferred Brand $93.00$279.00P Q:30
/30Days
DALIRESP 500 MCG TABLET   4 Non-Preferred Brand $93.00$279.00P Q:30
/30Days
DALVANCE 500 MG VIAL   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DANAZOL 100 MG CAPSULE [Danocrine]   2 Generic $10.00$30.00P
DANAZOL 50MG CAPSULE   2 Generic $10.00$30.00P
DANAZOL CAPSULES USP 200MG (100 CT)   2 Generic $10.00$30.00P
DANTRIUM 25 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
DANTRIUM 50 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
DANTROLENE SODIUM 100MG CAPSULE   2 Generic $10.00$30.00None
DANTROLENE SODIUM 25MG CAPSULE   2 Generic $10.00$30.00None
DANTROLENE SODIUM 50MG CAPSULE   2 Generic $10.00$30.00None
DAPSONE 100 MG TABLET   2 Generic $10.00$30.00None
DAPSONE 25 MG TABLET   2 Generic $10.00$30.00None
DAPTACEL DTAP VACCINE VIAL   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DAPTOMYCIN 500 MG VIAL [Cubicin RF]   5 Specialty Tier 33%N/ANone
DARAPRIM 25 MG TABLET   5 Specialty Tier 33%N/ANone
DAURISMO 100 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
DAURISMO 25 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
DAYPRO 600MG CAPLET   4 Non-Preferred Brand $93.00$279.00Q:90
/30Days
DDAVP 0.01% NASAL SPRAY   4 Non-Preferred Brand $93.00$279.00None
DDAVP 0.1 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DDAVP 0.2 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DEBLITANE 0.35 MG TABLET   2 Generic $10.00$30.00None
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 33%N/AP
DEFERASIROX 180 MG TABLET [Jadenu]   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 33%N/AP
DEFERASIROX 360 MG TABLET [Jadenu]   5 Specialty Tier 33%N/AP
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 33%N/AP
DEFERASIROX 90 MG TABLET [Jadenu]   5 Specialty Tier 33%N/AP
DELSTRIGO 100-300-300 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
DELZICOL DR 400 MG CAPSULE   3 Preferred Brand $40.00$120.00Q:180
/30Days
DEMECLOCYCLINE 150 MG TABLET [Declomycin]   2 Generic $10.00$30.00None
DEMECLOCYCLINE 300 MG TABLET [Declomycin]   2 Generic $10.00$30.00None
DEMSER CAPSULES 250MG (100 CT)   5 Specialty Tier 33%N/ANone
DENAVIR 1% CREAM (g)   5 Specialty Tier 33%N/ANone
DEPAKOTE 125MG SPRINKLE CAPSULE   4 Non-Preferred Brand $93.00$279.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEPAKOTE 125MG TABLET EC   4 Non-Preferred Brand $93.00$279.00None
DEPAKOTE DR 250 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DEPAKOTE DR 500 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DEPAKOTE ER 250MG TABLET SA   4 Non-Preferred Brand $93.00$279.00None
DEPAKOTE ER 500MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DEPEN 250MG TITRATAB   5 Specialty Tier 33%N/ANone
DEPO-PROVERA 150 MG/ML VIAL   4 Non-Preferred Brand $93.00$279.00None
DEPO-PROVERA 400MG/ML VIAL   4 Non-Preferred Brand $93.00$279.00None
DEPO-TESTOSTERONE 100 MG/ML VIAL   4 Non-Preferred Brand $93.00$279.00P
DEPO-TESTOSTERONE 200 MG/ML VIAL   4 Non-Preferred Brand $93.00$279.00P
DESCOVY 200-25 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE 10 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESIPRAMINE 100 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESIPRAMINE 150 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESIPRAMINE 25 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESIPRAMINE 50 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESIPRAMINE 75 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESLORATADINE 5 MG TABLET   2 Generic $10.00$30.00None
DESMOPRESSIN ACETATE 0.1 MG TABLET   2 Generic $10.00$30.00None
DESMOPRESSIN ACETATE 0.2 MG TABLET   2 Generic $10.00$30.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   2 Generic $10.00$30.00None
DESOGEST-ETH ESTRA 0.15-0.03MG TABLET [Solia]   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea]   2 Generic $10.00$30.00None
Desonide 0.0005 MG/MG Topical Ointment   2 Generic $10.00$30.00Q:120
/30Days
DESONIDE 0.05% CREAM (g) [Tridesilon]   2 Generic $10.00$30.00Q:120
/30Days
DESONIDE 0.05% LOTION [LoKara]   2 Generic $10.00$30.00Q:118
/30Days
DESOXIMETASONE 0.25% CREAM   2 Generic $10.00$30.00Q:120
/30Days
DESOXIMETASONE 0.25% OINTMENT [Topicort]   2 Generic $10.00$30.00Q:120
/30Days
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   2 Generic $10.00$30.00Q:120
/30Days
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   2 Generic $10.00$30.00Q:120
/30Days
DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq]   2 Generic $10.00$30.00Q:30
/30Days
DESVENLAFAXINE SUC ER 25 MG TABLET ER 24H [Pristiq]   2 Generic $10.00$30.00Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tablet [Pristiq]   2 Generic $10.00$30.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DETROL 1 MG TABLET   4 Non-Preferred Brand $93.00$279.00S Q:60
/30Days
DETROL 2 MG TABLET   4 Non-Preferred Brand $93.00$279.00S Q:60
/30Days
DETROL LA 2 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00S Q:30
/30Days
DETROL LA 4 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00S Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   3 Preferred Brand $40.00$120.00None
DEXAMETHASONE 0.5MG TABLET   1 Preferred Generic $3.00$9.00None
DEXAMETHASONE 0.5MG/5ML ELX   2 Generic $10.00$30.00None
DEXAMETHASONE 0.75MG TABLET   1 Preferred Generic $3.00$9.00None
DEXAMETHASONE 1.5MG TABLET   1 Preferred Generic $3.00$9.00None
DEXAMETHASONE 10 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   1 Preferred Generic $3.00$9.00None
DEXAMETHASONE 13 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 1MG TABLET   3 Preferred Brand $40.00$120.00None
DEXAMETHASONE 2MG TABLET   3 Preferred Brand $40.00$120.00None
DEXAMETHASONE 4MG TABLET   2 Generic $10.00$30.00None
DEXAMETHASONE 6 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   1 Preferred Generic $3.00$9.00None
DEXAMETHASONE 6MG TABLET   2 Generic $10.00$30.00None
DEXEDRINE SPANSULE 10 MG CAPSULE ER   5 Specialty Tier 33%N/AQ:120
/30Days
DEXEDRINE SPANSULE 15 MG CAPSULE ER   5 Specialty Tier 33%N/AQ:120
/30Days
DEXEDRINE SPANSULE 5 MG CAPSULE ER   5 Specialty Tier 33%N/AQ:90
/30Days
DEXMETHYLPHENIDATE 10 MG TABLET [Focalin]   2 Generic $10.00$30.00Q:60
/30Days
DEXMETHYLPHENIDATE 2.5 MG TABLET [Focalin]   2 Generic $10.00$30.00Q:60
/30Days
DEXMETHYLPHENIDATE 5 MG TABLET [Focalin]   2 Generic $10.00$30.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMP-AMPHET ER 10 MG CAPSULE ER 24H [Adderall XR]   2 Generic $10.00$30.00Q:30
/30Days
DEXTROAMP-AMPHET ER 15 MG CAPSULE ER 24H [Adderall XR]   2 Generic $10.00$30.00Q:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAPSULE ER 24H [Adderall XR]   2 Generic $10.00$30.00Q:30
/30Days
DEXTROAMP-AMPHET ER 25 MG CAPSULE ER 24H [Mydayis]   2 Generic $10.00$30.00Q:30
/30Days
DEXTROAMP-AMPHET ER 30 MG CAPSULE ER 24H [Adderall XR]   2 Generic $10.00$30.00Q:30
/30Days
DEXTROAMP-AMPHET ER 5 MG CAPSULE ER 24H [Adderall XR]   2 Generic $10.00$30.00Q:30
/30Days
DEXTROAMP-AMPHETAMIN 20 MG TABLET   2 Generic $10.00$30.00Q:90
/30Days
DEXTROAMP-AMPHETAMIN 30 MG TABLET   2 Generic $10.00$30.00Q:60
/30Days
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi]   2 Generic $10.00$30.00Q:180
/30Days
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi]   2 Generic $10.00$30.00Q:90
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   2 Generic $10.00$30.00Q:60
/30Days
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   1 Preferred Generic $3.00$9.00None
DEXTROSE 2.5%-1/2NS IV SOLUTION   1 Preferred Generic $3.00$9.00None
DEXTROSE 5%-0.2% NACL IV SOLUTION   1 Preferred Generic $3.00$9.00None
DEXTROSE 5%-0.45% NACL IV SOLUTION   2 Generic $10.00$30.00None
DEXTROSE 5%-0.9% NACL IV SOLUTION   2 Generic $10.00$30.00None
DEXTROSE 5%-WATER IV SOLUTION   2 Generic $10.00$30.00None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Brand $93.00$279.00Q:5
/30Days
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Brand $93.00$279.00Q:5
/30Days
DIASTAT ACUDIAL 5-7.5-10 MG KIT   4 Non-Preferred Brand $93.00$279.00Q:5
/30Days
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat]   4 Non-Preferred Brand $93.00$279.00Q:5
/30Days
DIAZEPAM 10 MG TABLET [Valium]   1 Preferred Generic $3.00$9.00P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIAZEPAM 2 MG TABLET [Valium]   1 Preferred Generic $3.00$9.00P Q:120
/30Days
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat]   4 Non-Preferred Brand $93.00$279.00Q:5
/30Days
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat]   4 Non-Preferred Brand $93.00$279.00Q:5
/30Days
DIAZEPAM 5 MG TABLET [Valium]   1 Preferred Generic $3.00$9.00P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   3 Preferred Brand $40.00$120.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2 Generic $10.00$30.00P Q:240
/30Days
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem]   2 Generic $10.00$30.00None
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2 Generic $10.00$30.00None
DICLOFENAC POT 50 MG TABLET [Cataflam]   2 Generic $10.00$30.00Q:120
/30Days
DICLOFENAC SOD EC 25 MG TABLET   2 Generic $10.00$30.00Q:240
/30Days
DICLOFENAC SOD EC 50 MG TABLET   2 Generic $10.00$30.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC SOD EC 75 MG TABLET   2 Generic $10.00$30.00Q:60
/30Days
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR]   2 Generic $10.00$30.00Q:60
/30Days
Diclofenac Sodium 1% gel   2 Generic $10.00$30.00P
Diclofenac Sodium 3% gel   2 Generic $10.00$30.00None
DICLOFENAC-MISOPROST 50-200 TABLET IR DR [Arthrotec]   2 Generic $10.00$30.00Q:120
/30Days
DICLOFENAC-MISOPROST 75-200 TABLET IR DR [Arthrotec]   2 Generic $10.00$30.00Q:90
/30Days
DICLOXACILLIN 250MG CAPSULE   2 Generic $10.00$30.00None
DICLOXACILLIN SODIUM 500MG CAPSULE   2 Generic $10.00$30.00None
DICYCLOMINE 10 MG CAPSULE [Bentyl]   3 Preferred Brand $40.00$120.00P
DICYCLOMINE 20 MG TABLET [Bentyl]   4 Non-Preferred Brand $93.00$279.00P
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   2 Generic $10.00$30.00Q: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]   2 Generic $10.00$30.00Q:30
/30Days
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 33%N/ANone
DIFLORASONE 0.05% OINTMENT   2 Generic $10.00$30.00Q:120
/30Days
DIFLUCAN 100MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DIFLUCAN 150MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DIFLUCAN 200MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DIFLUCAN 200MG/5ML SUSPEN   4 Non-Preferred Brand $93.00$279.00None
DIFLUCAN 50MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DIFLUCAN 50MG/5ML SUSPEN   4 Non-Preferred Brand $93.00$279.00None
DIGITEK 125 MCG TABLET   2 Generic $10.00$30.00Q:30
/30Days
DIGITEK 250 MCG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOX 125 MCG TABLET   2 Generic $10.00$30.00Q:30
/30Days
DIGOX 250 MCG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   2 Generic $10.00$30.00Q:150
/30Days
DIGOXIN 0.25 MG TABLET [Lanoxin]   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $10.00$30.00Q:30
/30Days
DIHYDROERGOTAMINE 4 MG/ML SPRAY   3 Preferred Brand $40.00$120.00Q:8
/28Days
DILANTIN 50MG INFATAB   4 Non-Preferred Brand $93.00$279.00None
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Brand $93.00$279.00None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   4 Non-Preferred Brand $93.00$279.00None
DILANTIN-125 SUS 125/5ML   4 Non-Preferred Brand $93.00$279.00None
DILT XR 120 MG CAPSULE   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILT XR 180 MG CAPSULE   2 Generic $10.00$30.00None
DILT XR 240 MG CAPSULE   2 Generic $10.00$30.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $10.00$30.00None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   2 Generic $10.00$30.00None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   2 Generic $10.00$30.00None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   2 Generic $10.00$30.00None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   2 Generic $10.00$30.00None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   2 Generic $10.00$30.00None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   2 Generic $10.00$30.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   2 Generic $10.00$30.00None
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac]   2 Generic $10.00$30.00None
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 Generic $10.00$30.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $10.00$30.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $10.00$30.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $10.00$30.00None
DIOVAN 160MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
DIOVAN 320MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIOVAN 40MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
DIOVAN 80MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
DIOVAN HCT 160/12.5MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIOVAN HCT 160/25MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIOVAN HCT 320/12.5MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIOVAN HCT 320/25MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIOVAN HCT 80/12.5MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
DIPENTUM 250 MG CAPSULE   5 Specialty Tier 33%N/ANone
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $40.00$120.00None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $40.00$120.00None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $40.00$120.00None
DIPROLENE 0.05% OINTMENT   4 Non-Preferred Brand $93.00$279.00Q:200
/28Days
DIPYRIDAMOLE 25 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DIPYRIDAMOLE 50 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DIPYRIDAMOLE 75 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
DISULFIRAM 250 MG TABLET   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DISULFIRAM 500 MG TABLET   2 Generic $10.00$30.00None
DITROPAN XL 10 MG TABLET   4 Non-Preferred Brand $93.00$279.00S Q:90
/30Days
DITROPAN XL 5 MG TABLET   4 Non-Preferred Brand $93.00$279.00S Q:30
/30Days
DIVALPROEX DR 125 MG CAPSULE SPRNK   2 Generic $10.00$30.00None
DIVALPROEX SOD DR 125 MG TABLET   2 Generic $10.00$30.00None
DIVALPROEX SOD DR 250 MG TABLET   2 Generic $10.00$30.00None
DIVALPROEX SOD DR 500 MG TABLET   2 Generic $10.00$30.00None
DIVALPROEX SOD ER 250 MG TABLET ER 24H [Depakote ER]   2 Generic $10.00$30.00None
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER]   2 Generic $10.00$30.00None
DIVIGEL 1 MG GEL PACKET   4 Non-Preferred Brand $93.00$279.00None
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   2 Generic $10.00$30.00None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   2 Generic $10.00$30.00None
DOLOPHINE HCL 10MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:360
/30Days
DOLOPHINE HYDROCHLORIDE 5mg 100 TABLET BOTTLE   4 Non-Preferred Brand $93.00$279.00Q:180
/30Days
DONEPEZIL HCL 10 MG TABLET   1 Preferred Generic $3.00$9.00None
DONEPEZIL HCL 23 MG TABLET [Aricept]   2 Generic $10.00$30.00None
DONEPEZIL HCL 5 MG TABLET   1 Preferred Generic $3.00$9.00None
DONEPEZIL HCL ODT 10 MG TABLET   2 Generic $10.00$30.00None
DONEPEZIL HCL ODT 5 MG TABLET   2 Generic $10.00$30.00None
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt]   2 Generic $10.00$30.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   2 Generic $10.00$30.00None
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]   4 Non-Preferred Brand $93.00$279.00None
DOTTI 0.0375 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Brand $93.00$279.00None
DOTTI 0.05 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Brand $93.00$279.00None
DOTTI 0.075 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Brand $93.00$279.00None
DOTTI 0.1 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Brand $93.00$279.00None
DOVATO 50-300 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
DOVONEX CREAM   5 Specialty Tier 33%N/ANone
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura]   2 Generic $10.00$30.00Q:60
/30Days
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura]   2 Generic $10.00$30.00Q:60
/30Days
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura]   2 Generic $10.00$30.00Q:60
/30Days
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura]   2 Generic $10.00$30.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN 10 MG/ML ORAL CONC   3 Preferred Brand $40.00$120.00None
DOXEPIN 10MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
DOXEPIN 50 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
DOXEPIN 75MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
DOXEPIN HCL 25MG CAPSULE (100 CT)   4 Non-Preferred Brand $93.00$279.00None
DOXEPIN HCL 3 MG TABLET [Silenor]   2 Generic $10.00$30.00Q:30
/30Days
DOXEPIN HCL 6 MG TABLET [Silenor]   2 Generic $10.00$30.00Q:30
/30Days
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Brand $93.00$279.00None
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   4 Non-Preferred Brand $93.00$279.00None
DOXY 100 VIAL   2 Generic $10.00$30.00None
Doxycycline 75mg/1   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 100 MG CAPSULE   2 Generic $10.00$30.00None
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs]   2 Generic $10.00$30.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   2 Generic $10.00$30.00None
DOXYCYCLINE HYCLATE 50 MG CAPSULE   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 100 MG CAPSULE   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 100 MG TABLET   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 150 MG CAPSULE [Adoxa]   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 150 MG TABLET   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox]   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 50 MG TABLET   2 Generic $10.00$30.00None
DOXYCYCLINE MONO 75 MG TABLET   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DRIZALMA SPRINKLE DR 20 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
DRIZALMA SPRINKLE DR 30 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00Q:90
/30Days
DRIZALMA SPRINKLE DR 40 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
DRIZALMA SPRINKLE DR 60 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
DRONABINOL 10 MG CAPSULE [Marinol]   2 Generic $10.00$30.00P
DRONABINOL 2.5 MG CAPSULE [Marinol]   2 Generic $10.00$30.00P
DRONABINOL 5 MG CAPSULE [Marinol]   2 Generic $10.00$30.00P
DROSP-EE-LEVOMEF 3-0.02-0.451 [Beyaz, Safyral]   2 Generic $10.00$30.00None
DROSPIRENONE-EE 3-0.02 MG TABLET   2 Generic $10.00$30.00None
DROSPIRENONE-EE 3-0.03 MG TABLET   2 Generic $10.00$30.00None
DUAVEE 0.45-20 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DULERA 50 MCG-5 MCG INHALER HFA AEROSOL AD   4 Non-Preferred Brand $93.00$279.00Q:13
/30Days
DULERA INHALATION AEROSOL   4 Non-Preferred Brand $93.00$279.00Q:13
/30Days
DULERA INHALATION AEROSOL   4 Non-Preferred Brand $93.00$279.00Q:13
/30Days
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta]   2 Generic $10.00$30.00Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta]   2 Generic $10.00$30.00Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta]   2 Generic $10.00$30.00Q:60
/30Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 33%N/AP
DUPIXENT 300 MG/2 ML SAFE SYRINGE   5 Specialty Tier 33%N/AP
duramorph 0.5 mg/ml ampule   2 Generic $10.00$30.00P
duramorph 1 mg/ml ampule   2 Generic $10.00$30.00P
DUREZOL 0.05% EYE DROPS   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DUTASTERIDE 0.5 MG CAPSULE [Avodart]   2 Generic $10.00$30.00Q:30
/30Days
DUTASTERIDE-TAMSULOSIN 0.5-0.4 CPMP 24HR [Jalyn]   2 Generic $10.00$30.00Q:30
/30Days
DYAZIDE 37.5-25 CAPSULE   4 Non-Preferred Brand $93.00$279.00None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D BlueMedicare Complete Rx (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.