2023 Medicare Part D Plan Formulary Information |
Blue Rx Standard (PDP) (S3375-001-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Blue Rx Standard (PDP) (S3375-001-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 3 which includes: NY
|
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 |
DABIGATRAN ETEXILATE 150 MG CP CAPSULE [Pradaxa] |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
DABIGATRAN ETEXILATE 75 CAPSULE [Pradaxa] |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
DALFAMPRIDINE ER 10 MG TABLET 12H [Ampyra] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:60 /30Days |
DALIRESP 250 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
DALIRESP 500 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
DANAZOL 100 MG CAPSULE [Danocrine] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DANAZOL 50MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
4 |
Non-Preferred Drug |
40% | 40% | None |
DANTROLENE SODIUM 100MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
DANTROLENE SODIUM 25MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DANTROLENE SODIUM 50MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
DAPSONE 100 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DAPSONE 25 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DAPTACEL DTAP VACCINE VIAL |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DAPTOMYCIN 500 MG VIAL [Cubicin RF] |
5 |
Specialty Tier |
25% | N/A | None |
DARUNAVIR 600 MG TABLET [Prezista] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
DARUNAVIR 800 MG TABLET [Prezista] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
DAURISMO 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
DAURISMO 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
DEBLITANE 0.35 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEFERASIROX 125 MG TB FOR SUSPENSION TABLET DISPER [Exjade] |
3 |
Preferred Brand |
$46.00 | $138.00 | 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 |
Specialty Tier |
25% | N/A | P |
DEFERASIROX 500 MG TB FOR SUSPENSION TABLET DISPER [Exjade] |
5 |
Specialty Tier |
25% | N/A | P |
DELSTRIGO 100-300-300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
DEPO-TESTOSTERONE 100 MG/ML VIAL |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DEPO-TESTOSTERONE 200 MG/ML VIAL |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DESCOVY 120-15 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
DESCOVY 200-25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
DESIPRAMINE 10 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DESIPRAMINE 100 MG TABLET [Norpramin] |
4 |
Non-Preferred Drug |
40% | 40% | P |
DESIPRAMINE 150 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DESIPRAMINE 25 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESIPRAMINE 50 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DESIPRAMINE 75 MG TABLET [Norpramin] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DESMOPRESSIN 10 MCG/0.1 ML SPR SPRAY/PUMP [Minirin] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DESMOPRESSIN ACETATE 0.1 MG TABLET [DDAVP] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TABLET [DDAVP] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DESOGESTREL-EE 0.15-0.03 MG TABLET [Solia] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DESONIDE 0.05% OINTMENT [Tridesilon] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DESVENLAFAXINE SUCCNT ER 100 MG TABLET 24H [Pristiq] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DESVENLAFAXINE SUCCNT ER 25 MG TABLET 24H [Pristiq] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DESVENLAFAXINE SUCCNT ER 50 MG TABLET 24H [Pristiq] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.1% EYE DROP |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 0.5 MG/5 ML LIQ SOLUTION |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 0.5MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 0.75MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 1.5MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 1MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 2MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 4MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXAMETHASONE 6MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DEXTROAMP-AMPHETAMIN 20 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:90 /30Days |
DEXTROAMP-AMPHETAMIN 30 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:180 /30Days |
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:90 /30Days |
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT) |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:90 /30Days |
DEXTROSE 10%-1/4NS IV TUBEX |
4 |
Non-Preferred Drug |
40% | 40% | None |
DEXTROSE 10%-WATER IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
DEXTROSE 5%-0.2% NACL IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
DEXTROSE 5%-0.45% NACL IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
DEXTROSE 5%-0.9% NACL IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
DEXTROSE 5%-WATER IV SOLUTION PGY VL PRT |
4 |
Non-Preferred Drug |
40% | 40% | None |
DEXTROSE IN SODIUM CHLORIDE INJECTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
DIACOMIT 250 MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | P Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIACOMIT 250 MG POWDER PACK |
4 |
Non-Preferred Drug |
40% | 40% | P Q:360 /30Days |
DIACOMIT 500 MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
DIACOMIT 500 MG POWDER PACK |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DIAZEPAM 10 MG TABLET [Valium] |
2* |
Generic |
$1.00 | $3.00 | Q:120 /30Days |
DIAZEPAM 2 MG TABLET [Valium] |
2* |
Generic |
$1.00 | $3.00 | Q:600 /30Days |
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DIAZEPAM 5 MG TABLET [Valium] |
2* |
Generic |
$1.00 | $3.00 | Q:240 /30Days |
DIAZEPAM 5 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:1200 /30Days |
DIAZEPAM 5 MG/ML ORAL CONC |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DICLOFENAC 0.1% EYE DROPS [Voltaren Ophthalmic] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DICLOFENAC POT 50 MG TABLET [Cataflam] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DICLOFENAC SOD EC 25 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
DICLOFENAC SOD EC 50 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
DICLOFENAC SOD EC 75 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DICLOFENAC SODIUM 1% GEL [Voltaren Gel] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:1000 /30Days |
DICLOXACILLIN 250MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DICLOXACILLIN SODIUM 500MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DICYCLOMINE 10 MG CAPSULE [Bentyl] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICYCLOMINE 20 MG TABLET [Bentyl] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
4 |
Non-Preferred Drug |
40% | 40% | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | P |
DIFICID 40 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
25% | N/A | P |
DIFLUNISAL 500 MG TABLET [Dolobid] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIFLUPREDNATE 0.05% EYE DROPS [Durezol] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DIGOXIN 125 MCG TABLET [Lanoxin] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIGOXIN 250 MCG TABLET [Lanoxin] |
4 |
Non-Preferred Drug |
40% | 40% | P |
DIHYDROERGOTAMINE 4 MG/ML SPRAY/PUMP [TRUDHESA] |
4 |
Non-Preferred Drug |
40% | 40% | Q:8 /28Days |
DILANTIN CAPSULES 30 MG ER |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILT XR 120 MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILT XR 180 MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILT XR 240 MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2* |
Generic |
$1.00 | $3.00 | None |
DILTIAZEM 24H ER(CD) 120 MG CAPSULE ER 24H [Tiazac] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 24H ER(CD) 180 MG CAPSULE ER 24H [Tiazac] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 24H ER(CD) 240 MG CAPSULE ER 24H [Tiazac] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 24H ER(CD) 300 MG CAPSULE ER 24H [Tiazac] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2* |
Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DILTIAZEM 60 MG TABLET [Cardizem] |
2* |
Generic |
$1.00 | $3.00 | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
2* |
Generic |
$1.00 | $3.00 | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIPHENOXYLATE-ATROP 2.5-0.025 TABLET [Vi-Atro] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
4 |
Non-Preferred Drug |
40% | 40% | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DISULFIRAM 250 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DISULFIRAM 500 MG TABLET [Antabuse] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DIVALPROEX DR 125 MG CAPSULE SPRNK |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIVALPROEX SOD DR 125 MG TABLET DR [Depakote] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIVALPROEX SOD DR 250 MG TABLET DR [Depakote] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIVALPROEX SOD DR 500 MG TABLET DR [Depakote] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIVALPROEX SOD ER 250 MG TABLET 24H [Depakote ER] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DOFETILIDE 250 MCG CAPSULE [Tikosyn] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
4 |
Non-Preferred Drug |
40% | 40% | None |
DONEPEZIL HCL 10 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | Q:30 /30Days |
DONEPEZIL HCL 5 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | Q:30 /30Days |
DONEPEZIL HCL ODT 10 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
DONEPEZIL HCL ODT 5 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt] |
2* |
Generic |
$1.00 | $3.00 | None |
DORZOLAMIDE-TIMOLOL EYE DROPS [Cosopt PF] |
2* |
Generic |
$1.00 | $3.00 | None |
DOTTI 0.025 MG PATCH TDSW [Vivelle-Dot] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
DOTTI 0.0375 MG PATCH TDSW [Vivelle-Dot] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
DOTTI 0.05 MG PATCH TDSW [Vivelle-Dot] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
DOTTI 0.075 MG PATCH TDSW [Vivelle-Dot] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
DOTTI 0.1 MG PATCH TDSW [Vivelle-Dot] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
DOVATO 50-300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura] |
2* |
Generic |
$1.00 | $3.00 | None |
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura] |
2* |
Generic |
$1.00 | $3.00 | None |
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura] |
2* |
Generic |
$1.00 | $3.00 | 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* |
Generic |
$1.00 | $3.00 | None |
DOXEPIN 10 MG CAPSULE [Sinequan] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DOXEPIN 10 MG/ML ORAL CONC [Sinequan] |
4 |
Non-Preferred Drug |
40% | 40% | P |
DOXEPIN 100 MG CAPSULE [Sinequan] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DOXEPIN 25 MG CAPSULE [Sinequan] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DOXEPIN 50 MG CAPSULE [Sinequan] |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DOXEPIN 75MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
DOXY 100 VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
DOXYCYCLINE HYCLATE 100 MG CAPSULE [Vibramycin] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DOXYCYCLINE HYCLATE 50 MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DOXYCYCLINE MONO 100 MG CAPSULE [Monodox] |
2* |
Generic |
$1.00 | $3.00 | None |
DOXYCYCLINE MONO 100 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox] |
2* |
Generic |
$1.00 | $3.00 | None |
DOXYCYCLINE MONO 50 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DOXYCYCLINE MONO 75 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DRONABINOL 10 MG CAPSULE [Marinol] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:120 /30Days |
DRONABINOL 2.5 MG CAPSULE [Marinol] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:120 /30Days |
DRONABINOL 5 MG CAPSULE [Marinol] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:120 /30Days |
DROSPIRENONE-EE 3-0.02 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | 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 [Zumandimine] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DROXIA 200MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DROXIA 300MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DROXIA 400MG CAPSULE |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
DROXIDOPA 100 MG CAPSULE [NORTHERA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:90 /30Days |
DROXIDOPA 200 MG CAPSULE [NORTHERA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
DROXIDOPA 300 MG CAPSULE [NORTHERA] |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
DUAVEE 0.45-20 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:180 /30Days |
DULOXETINE HCL DR 30 MG CAPSULE DR [Drizalma] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:120 /30Days |
DULOXETINE HCL DR 60 MG CAPSULE DR [Drizalma] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DUPIXENT 100 MG/0.67 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
DUPIXENT 200 MG/1.14 ML PEN INJCTR |
5 |
Specialty Tier |
25% | N/A | P Q:5 /28Days |
DUPIXENT 200 MG/1.14 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:5 /28Days |
DUPIXENT 300 MG/2 ML PEN INJECTOR |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
DUPIXENT 300 MG/2 ML SAFE SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:30 /30Days |