2021 Medicare Part D Plan Formulary Information |
MMM Diamante Platino (HMO D-SNP) (H4003-017-0)
Benefit Details
|
The MMM Diamante Platino (HMO D-SNP) (H4003-017-0) Formulary Drugs Starting with the Letter D in Juncos County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $445 |
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 |
D5%-1/2NS-KCL 10 MEQ/L IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
D5%-1/2NS-KCL 30 MEQ/L IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
D5%-1/2NS-KCL 40 MEQ/L IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra] |
5 |
Tier 5 |
15% | 15% | P Q:60 /30Days |
DALIRESP 250 MCG TABLET |
4 |
Tier 4 |
15% | 15% | None |
DALIRESP 500 MCG TABLET |
4 |
Tier 4 |
15% | 15% | None |
DANAZOL 100 MG CAPSULE [Danocrine] |
2 |
Tier 2 |
15% | 15% | None |
DANAZOL 50MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
DANTROLENE SODIUM 100MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTROLENE SODIUM 25MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DANTROLENE SODIUM 50MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DAPSONE 100 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DAPSONE 25 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DAPTACEL DTAP VACCINE VIAL |
3 |
Tier 3 |
15% | 15% | None |
DAPTOMYCIN 350 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
15% | 15% | None |
DAPTOMYCIN 500 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
15% | 15% | None |
DAURISMO 100 MG TABLET |
5 |
Tier 5 |
15% | 15% | P Q:28 /28Days |
DAURISMO 25 MG TABLET |
5 |
Tier 5 |
15% | 15% | P Q:56 /28Days |
DEBLITANE 0.35 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEFERASIROX 125 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEFERASIROX 250 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
15% | 15% | P |
DEFERASIROX 500 MG TABLET DISPER [Exjade] |
5 |
Tier 5 |
15% | 15% | P |
DEFERIPRONE 500 MG TABLET [Ferriprox] |
5 |
Tier 5 |
15% | 15% | P |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
DESCOVY 200-25 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
DESIPRAMINE 10 MG TABLET [Norpramin] |
2 |
Tier 2 |
15% | 15% | P |
DESIPRAMINE 100 MG TABLET [Norpramin] |
2 |
Tier 2 |
15% | 15% | P |
DESIPRAMINE 150 MG TABLET [Norpramin] |
2 |
Tier 2 |
15% | 15% | P |
DESIPRAMINE 25 MG TABLET [Norpramin] |
2 |
Tier 2 |
15% | 15% | P |
DESIPRAMINE 50 MG TABLET [Norpramin] |
2 |
Tier 2 |
15% | 15% | P |
DESIPRAMINE 75 MG TABLET [Norpramin] |
2 |
Tier 2 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESLORATADINE 5 MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DESMOPRESSIN ACETATE 0.1 MG TABLET [DDAVP] |
2 |
Tier 2 |
15% | 15% | None |
DESMOPRESSIN ACETATE 0.2 MG TABLET [DDAVP] |
2 |
Tier 2 |
15% | 15% | None |
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR |
2 |
Tier 2 |
15% | 15% | None |
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea] |
2 |
Tier 2 |
15% | 15% | None |
DESONIDE 0.05% CREAM (g) [Tridesilon] |
2 |
Tier 2 |
15% | 15% | None |
DESONIDE 0.05% LOTION [LoKara] |
2 |
Tier 2 |
15% | 15% | None |
DESONIDE 0.05% OINTMENT [Tridesilon] |
2 |
Tier 2 |
15% | 15% | None |
Desoximetasone 0.0005 MG/MG Topical Ointment |
2 |
Tier 2 |
15% | 15% | None |
DESOXIMETASONE 0.05% CREAM (G) [Topicort LP] |
2 |
Tier 2 |
15% | 15% | None |
DESOXIMETASONE 0.25% CREAM |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESOXIMETASONE 0.25% OINTMENT [Topicort] |
2 |
Tier 2 |
15% | 15% | None |
DESOXIMETASONE 0.25% SPRAY [Topicort] |
2 |
Tier 2 |
15% | 15% | None |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
15% | 15% | None |
DESVENLAFAXINE ER 100 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DESVENLAFAXINE ER 50 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq] |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DESVENLAFAXINE SUC ER 25 MG TABLET ER 24H [Pristiq] |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DESVENLAFAXINE SUCCNT ER 50 MG TABLET ER 24H [Pristiq] |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DEXAMETHASONE 0.1% EYE DROP |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 0.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 0.5MG/5ML ELX |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.75MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 1.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 2MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 4MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXAMETHASONE 6MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DEXTROAMP-AMPHET ER 10 MG CAPSULE ER 24H [Adderall XR] |
2 |
Tier 2 |
15% | 15% | P Q:90 /30Days |
DEXTROAMP-AMPHET ER 15 MG CAPSULE ER 24H [Adderall XR] |
2 |
Tier 2 |
15% | 15% | P Q:30 /30Days |
DEXTROAMP-AMPHET ER 20 MG CAPSULE ER 24H [Adderall XR] |
2 |
Tier 2 |
15% | 15% | P Q:30 /30Days |
DEXTROAMP-AMPHET ER 25 MG CAPSULE ER 24H [Mydayis] |
2 |
Tier 2 |
15% | 15% | P Q:30 /30Days |
DEXTROAMP-AMPHET ER 30 MG CAPSULE ER 24H [Adderall XR] |
2 |
Tier 2 |
15% | 15% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMP-AMPHET ER 5 MG CAPSULE ER 24H [Adderall XR] |
2 |
Tier 2 |
15% | 15% | P Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 20 MG TABLET |
2 |
Tier 2 |
15% | 15% | P Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 30 MG TABLET |
2 |
Tier 2 |
15% | 15% | P Q:60 /30Days |
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi] |
2 |
Tier 2 |
15% | 15% | P |
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi] |
2 |
Tier 2 |
15% | 15% | P |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | P Q:180 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX |
2 |
Tier 2 |
15% | 15% | None |
DEXTROSE 10%-WATER IV SOLUTION DEHP FR BG |
2 |
Tier 2 |
15% | 15% | None |
DEXTROSE 2.5%-1/2NS IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
DEXTROSE 5%-0.2% NACL IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
DEXTROSE 5%-0.45% NACL IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROSE 5%-0.9% NACL IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
DEXTROSE 5%-WATER IV SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
2 |
Tier 2 |
15% | 15% | None |
DIACOMIT 250 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
DIACOMIT 250 MG POWDER PACK |
5 |
Tier 5 |
15% | 15% | P |
DIACOMIT 500 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
DIACOMIT 500 MG POWDER PACK |
5 |
Tier 5 |
15% | 15% | P |
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat] |
2 |
Tier 2 |
15% | 15% | None |
DIAZEPAM 10 MG TABLET [Valium] |
1 |
Tier 1 |
15% | 15% | P |
DIAZEPAM 2 MG TABLET [Valium] |
1 |
Tier 1 |
15% | 15% | P |
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat] |
2 |
Tier 2 |
15% | 15% | None |
DIAZEPAM 5 MG TABLET [Valium] |
1 |
Tier 1 |
15% | 15% | P |
DIAZEPAM 5 MG/5 ML SOLUTION |
2 |
Tier 2 |
15% | 15% | P |
DIAZEPAM 5 MG/ML ORAL CONC |
2 |
Tier 2 |
15% | 15% | P |
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem] |
2 |
Tier 2 |
15% | 15% | None |
DICLOFENAC 0.1% EYE DROPS [Voltaren] |
2 |
Tier 2 |
15% | 15% | None |
DICLOFENAC EPOLAMINE 1.3% PATCH TD12 [Licart] |
2 |
Tier 2 |
15% | 15% | None |
DICLOFENAC POT 50 MG TABLET [Cataflam] |
2 |
Tier 2 |
15% | 15% | None |
DICLOFENAC SOD EC 25 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DICLOFENAC SOD EC 50 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DICLOFENAC SOD EC 75 MG TABLET |
2 |
Tier 2 |
15% | 15% | 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 |
15% | 15% | None |
DICLOFENAC SODIUM 1% GEL [Voltaren Gel] |
2 |
Tier 2 |
15% | 15% | None |
DICLOXACILLIN 250MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DICLOXACILLIN SODIUM 500MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
DICYCLOMINE 10 MG CAPSULE [Bentyl] |
2 |
Tier 2 |
15% | 15% | P |
DICYCLOMINE 20 MG TABLET [Bentyl] |
2 |
Tier 2 |
15% | 15% | P |
DICYCLOMINE HCL 10MG/5ML SYRUP |
2 |
Tier 2 |
15% | 15% | P |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Tier 5 |
15% | 15% | S |
DIFICID 40 MG/ML ORAL SUSPENSION |
5 |
Tier 5 |
15% | 15% | S |
DIFLUNISAL 500 MG TABLET [Dolobid] |
2 |
Tier 2 |
15% | 15% | None |
DIGITEK 125 MCG TABLET |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIGITEK 250 MCG TABLET |
2 |
Tier 2 |
15% | 15% | P |
DIGOX 125 MCG TABLET |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DIGOX 250 MCG TABLET |
2 |
Tier 2 |
15% | 15% | P |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
2 |
Tier 2 |
15% | 15% | P |
DIGOXIN 125 MCG TABLET [Lanoxin] |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DIGOXIN 250 MCG TABLET [Lanoxin] |
2 |
Tier 2 |
15% | 15% | P |
DIHYDROERGOTAMINE 4 MG/ML SPRAY |
2 |
Tier 2 |
15% | 15% | None |
DILANTIN 125 MG/5 ML ORAL SUSPENSION |
4 |
Tier 4 |
15% | 15% | None |
DILANTIN 50MG INFATAB |
4 |
Tier 4 |
15% | 15% | None |
DILANTIN CAPSULES 30 MG ER |
4 |
Tier 4 |
15% | 15% | None |
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT) |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILT XR 120 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DILT XR 180 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DILT XR 240 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 24H ER(LA) 180 MG TABLET [Matzim LA] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24H ER(LA) 240 MG TABLET [Matzim LA] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24H ER(LA) 300 MG TABLET [Matzim LA] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24H ER(LA) 360 MG TABLET [Matzim LA] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac] |
2 |
Tier 2 |
15% | 15% | None |
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
1 |
Tier 1 |
15% | 15% | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
1 |
Tier 1 |
15% | 15% | None |
DIPENTUM 250 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Tier 3 |
15% | 15% | None |
DIPHENOXYLATE-ATROP 2.5-0.025 TABLET [Vi-Atro] |
2 |
Tier 2 |
15% | 15% | P |
DIPHENOXYLATE/ATROPINE LIQ |
2 |
Tier 2 |
15% | 15% | P |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Tier 3 |
15% | 15% | P |
DISULFIRAM 250 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DISULFIRAM 500 MG TABLET [Antabuse] |
2 |
Tier 2 |
15% | 15% | None |
DIVALPROEX DR 125 MG CAPSULE SPRNK |
2 |
Tier 2 |
15% | 15% | None |
DIVALPROEX SOD DR 125 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DIVALPROEX SOD DR 250 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DIVALPROEX SOD DR 500 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DIVALPROEX SOD ER 250 MG TABLET ER 24H [Depakote ER] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER] |
2 |
Tier 2 |
15% | 15% | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
2 |
Tier 2 |
15% | 15% | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
2 |
Tier 2 |
15% | 15% | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
2 |
Tier 2 |
15% | 15% | None |
DONEPEZIL HCL 10 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DONEPEZIL HCL 23 MG TABLET [Aricept] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DONEPEZIL HCL 5 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DONEPEZIL HCL ODT 10 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DONEPEZIL HCL ODT 5 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt] |
2 |
Tier 2 |
15% | 15% | None |
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL |
2 |
Tier 2 |
15% | 15% | 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 |
15% | 15% | None |
DOVATO 50-300 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura] |
1 |
Tier 1 |
15% | 15% | None |
DOXEPIN 10 MG/ML ORAL CONC |
2 |
Tier 2 |
15% | 15% | P |
DOXEPIN 10MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
DOXEPIN 5% CREAM (g) [Zonalon] |
2 |
Tier 2 |
15% | 15% | None |
DOXEPIN 50 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
DOXEPIN 75MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXEPIN HCL 25MG CAPSULE (100 CT) |
2 |
Tier 2 |
15% | 15% | P |
DOXEPIN HCL 3 MG TABLET [Silenor] |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
DOXEPIN HCL 6 MG TABLET [Silenor] |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | 15% | P |
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT |
2 |
Tier 2 |
15% | 15% | P |
DOXY 100 VIAL |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE HYC DR 80 MG TABLET DR [Doryx] |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE HYCLATE 100 MG CAPSULE [Vibramycin] |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs] |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE HYCLATE 150 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | 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 |
15% | 15% | None |
DOXYCYCLINE HYCLATE 75 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE MONO 100 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE MONO 150 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE MONO 50 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DOXYCYCLINE MONO 75 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
DRIZALMA SPRINKLE DR 20 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days |
DRIZALMA SPRINKLE DR 30 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days |
DRIZALMA SPRINKLE DR 40 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P Q:90 /30Days |
DRIZALMA SPRINKLE DR 60 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days |
DRONABINOL 10 MG CAPSULE [Marinol] |
2 |
Tier 2 |
15% | 15% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
2 |
Tier 2 |
15% | 15% | P Q:60 /30Days |
DRONABINOL 5 MG CAPSULE [Marinol] |
2 |
Tier 2 |
15% | 15% | P Q:60 /30Days |
DROSPIRENONE-EE 3-0.03 MG TABLET [Zumandimine] |
2 |
Tier 2 |
15% | 15% | None |
DROXIA 200MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
DROXIA 300MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
DROXIA 400MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
DROXIDOPA 100 MG CAPSULE [NORTHERA] |
5 |
Tier 5 |
15% | 15% | P |
DROXIDOPA 200 MG CAPSULE [NORTHERA] |
5 |
Tier 5 |
15% | 15% | P |
DROXIDOPA 300 MG CAPSULE [NORTHERA] |
5 |
Tier 5 |
15% | 15% | P |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
15% | 15% | None |
DULOXETINE HCL DR 30 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DULOXETINE HCL DR 40 MG CAPSULE [Irenka] |
2 |
Tier 2 |
15% | 15% | None |
DULOXETINE HCL DR 60 MG CAPSULE [Cymbalta] |
2 |
Tier 2 |
15% | 15% | None |
DUREZOL 0.05% EYE DROPS |
3 |
Tier 3 |
15% | 15% | None |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
2 |
Tier 2 |
15% | 15% | None |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 CPMP 24HR [Jalyn] |
2 |
Tier 2 |
15% | 15% | None |