2024 Medicare Part D Plan Formulary Information |
FHCP Medicare Rx Savings (HMO) (H1035-014-0)
Benefits & Contact Info
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 FHCP Medicare Rx Savings (HMO) (H1035-014-0) Formulary Drugs Starting with the Letter D in Brevard County, FL: CMS MA Region 9 which includes: FL
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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 |
DALFAMPRIDINE ER 10 MG TABLET 12H [Ampyra] |
2* |
Generic |
$10.00 | $27.00 | P |
DANAZOL 100 MG CAPSULE [Danocrine] |
2* |
Generic |
$10.00 | $27.00 | None |
DANAZOL 50MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
DANAZOL CAPSULES USP 200MG (100 CT) |
2* |
Generic |
$10.00 | $27.00 | None |
DANTROLENE SODIUM 50MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
DAPSONE 100 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DAPSONE 25 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DAPTACEL DTAP VACCINE VIAL |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DAPTOMYCIN 500 MG VIAL [Cubicin RF] |
5 |
Tier 5 |
25% | N/A | None |
DARUNAVIR 600 MG TABLET [Prezista] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DARUNAVIR 800 MG TABLET [Prezista] |
2* |
Generic |
$10.00 | $27.00 | None |
DAURISMO 100 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:30 /30Days |
DAURISMO 25 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:90 /30Days |
DEFERASIROX 125 MG TB FOR SUSPENSION TABLET DISPER [Exjade] |
2* |
Generic |
$10.00 | $27.00 | P |
DEFERASIROX 250 MG TABLET DISPER [Exjade] |
2* |
Generic |
$10.00 | $27.00 | P |
DEFERASIROX 500 MG TB FOR SUSPENSION TABLET DISPER [Exjade] |
2* |
Generic |
$10.00 | $27.00 | P |
DELSTRIGO 100-300-300 MG TABLET |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DEMECLOCYCLINE 150 MG TABLET [Declomycin] |
2* |
Generic |
$10.00 | $27.00 | None |
DEMECLOCYCLINE 300 MG TABLET [Declomycin] |
2* |
Generic |
$10.00 | $27.00 | None |
DEPO-ESTRADIOL 5MG/ML VIAL |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | None |
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESCOVY 120-15 MG TABLET |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DESCOVY 200-25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DESIPRAMINE 10 MG TABLET [Norpramin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESIPRAMINE 100 MG TABLET [Norpramin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESIPRAMINE 150 MG TABLET [Norpramin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESIPRAMINE 25 MG TABLET [Norpramin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESIPRAMINE 50 MG TABLET [Norpramin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESIPRAMINE 75 MG TABLET [Norpramin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESMOPRESSIN 0.01% SOLUTION SPRAY/PUMP [Minirin] |
2* |
Generic |
$10.00 | $27.00 | None |
DESMOPRESSIN ACETATE 0.1 MG TABLET [DDAVP] |
2* |
Generic |
$10.00 | $27.00 | None |
DESMOPRESSIN ACETATE 0.2 MG TABLET [DDAVP] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DESONIDE 0.05% CREAM (G) [Tridesilon] |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
DESONIDE 0.05% LOTION [LoKara] |
2* |
Generic |
$10.00 | $27.00 | Q:60 /30Days |
DESONIDE 0.05% OINTMENT [Tridesilon] |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
DESOXIMETASONE 0.05% CREAM (G) [Topicort LP] |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
DESOXIMETASONE 0.05% OINTMENT [Topicort LP] |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
DESOXIMETASONE 0.25% CREAM (G) [Topicort] |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
DESOXIMETASONE 0.25% OINTMENT [Topicort] |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Generic |
$10.00 | $27.00 | Q:120 /30Days |
DESVENLAFAXINE SUCCNT ER 100MG TABLET 24H [Pristiq] |
2* |
Generic |
$10.00 | $27.00 | None |
DESVENLAFAXINE SUCCNT ER 25 MG TABLET 24H [Pristiq] |
2* |
Generic |
$10.00 | $27.00 | None |
DESVENLAFAXINE SUCCNT ER 50 MG TABLET 24H [Pristiq] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXAMETHASONE 0.1% EYE DROP |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 0.5 MG/5 ML LIQ SOLUTION |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 0.5MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 0.75MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 1.5MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 1MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 2MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 4MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXAMETHASONE 6MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DEXMETHYLPHENIDATE 10 MG TABLET [Focalin] |
2* |
Generic |
$10.00 | $27.00 | Q:60 /30Days |
DEXMETHYLPHENIDATE 2.5 MG TABLET [Focalin] |
2* |
Generic |
$10.00 | $27.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXMETHYLPHENIDATE 5 MG TABLET [Focalin] |
2* |
Generic |
$10.00 | $27.00 | Q:60 /30Days |
DEXTROAMP-AMPHET ER 10 MG CAPSULE 24H [Adderall XR] |
2* |
Generic |
$10.00 | $27.00 | Q:31 /31Days |
DEXTROAMP-AMPHET ER 15 MG CAPSULE 24H [Adderall XR] |
2* |
Generic |
$10.00 | $27.00 | Q:31 /31Days |
DEXTROAMP-AMPHET ER 20 MG CAPSULE 24H [Adderall XR] |
2* |
Generic |
$10.00 | $27.00 | Q:62 /31Days |
DEXTROAMP-AMPHET ER 25 MG CAPSULE 24H [Mydayis] |
2* |
Generic |
$10.00 | $27.00 | Q:62 /31Days |
DEXTROAMP-AMPHET ER 30 MG CAPSULE 24H [Adderall XR] |
2* |
Generic |
$10.00 | $27.00 | Q:62 /31Days |
DEXTROAMP-AMPHET ER 5 MG CAPSULE 24H [Adderall XR] |
2* |
Generic |
$10.00 | $27.00 | Q:31 /31Days |
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi] |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi] |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROAMPHETAMINE ER 10 MG CAPSULE [Dexedrine Spansule] |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROAMPHETAMINE ER 15 MG CAPSULE [Dexedrine Spansule] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DEXTROAMPHETAMINE ER 5 MG CAPSULE [Dexedrine Spansule] |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROSE 10%-WATER IV SOLUTION |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROSE 5%-0.45% NACL IV SOLUTION |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROSE 5%-0.9% NACL IV SOLUTION |
2* |
Generic |
$10.00 | $27.00 | None |
DEXTROSE 5%-WATER IV SOLUTION PGY VL PRT |
2* |
Generic |
$10.00 | $27.00 | None |
DIACOMIT 250 MG CAPSULE |
5 |
Tier 5 |
25% | N/A | P |
DIACOMIT 250 MG POWDER PACK |
5 |
Tier 5 |
25% | N/A | P |
DIACOMIT 500 MG CAPSULE |
5 |
Tier 5 |
25% | N/A | P |
DIACOMIT 500 MG POWDER PACK |
5 |
Tier 5 |
25% | N/A | P |
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat] |
2* |
Generic |
$10.00 | $27.00 | Q:10 /30Days |
DIAZEPAM 10 MG TABLET [Valium] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIAZEPAM 2 MG TABLET [Valium] |
2* |
Generic |
$10.00 | $27.00 | None |
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat] |
2* |
Generic |
$10.00 | $27.00 | Q:10 /30Days |
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat] |
2* |
Generic |
$10.00 | $27.00 | Q:10 /30Days |
DIAZEPAM 5 MG TABLET [Valium] |
2* |
Generic |
$10.00 | $27.00 | None |
DIAZEPAM 5 MG/5 ML SOLUTION |
2* |
Generic |
$10.00 | $27.00 | None |
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem] |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | None |
DICLOFENAC 0.1% EYE DROPS [Voltaren Ophthalmic] |
2* |
Generic |
$10.00 | $27.00 | None |
DICLOFENAC SOD EC 25 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DICLOFENAC SOD EC 50 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DICLOFENAC SOD EC 75 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DICLOFENAC SODIUM 1% GEL [Voltaren Gel] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DICLOFENAC SODIUM 3% GEL [Solaraze] |
2* |
Generic |
$10.00 | $27.00 | P Q:100 /30Days |
DICLOXACILLIN 250MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
DICLOXACILLIN SODIUM 500MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
DICYCLOMINE 10 MG CAPSULE [Bentyl] |
2* |
Generic |
$10.00 | $27.00 | None |
DICYCLOMINE 20 MG TABLET [Bentyl] |
2* |
Generic |
$10.00 | $27.00 | None |
DICYCLOMINE HCL 10MG/5ML SYRUP |
2* |
Generic |
$10.00 | $27.00 | None |
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE |
5 |
Tier 5 |
25% | N/A | P |
DIFLUPREDNATE 0.05% EYE DROPS [Durezol] |
2* |
Generic |
$10.00 | $27.00 | None |
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin] |
2* |
Generic |
$10.00 | $27.00 | None |
DIGOXIN 125 MCG TABLET [Lanoxin] |
2* |
Generic |
$10.00 | $27.00 | None |
DIGOXIN 250 MCG TABLET [Lanoxin] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIHYDROERGOTAMINE 4 MG/ML SPRAY/PUMP [TRUDHESA] |
5 |
Tier 5 |
25% | N/A | None |
DILANTIN CAPSULES 30 MG ER |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DILTIAZEM 120 MG TABLET [Cardizem] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 24H ER(CD) 120 MG CAPSULE ER 24H [Tiazac] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 24H ER(CD) 180 MG CAPSULE ER 24H [Tiazac] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 24H ER(CD) 240 MG CAPSULE ER 24H [Tiazac] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 24H ER(CD) 300 MG CAPSULE ER 24H [Tiazac] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 30 MG TABLET [Cardizem] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 60 MG TABLET [Cardizem] |
2* |
Generic |
$10.00 | $27.00 | None |
DILTIAZEM 90 MG TABLET [Cardizem] |
2* |
Generic |
$10.00 | $27.00 | None |
DIMETHYL FUMARATE 30D START PK CAPSULE DR [Tecfidera] |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DIMETHYL FUMARATE DR 120 MG CAPSULE DR [Tecfidera] |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
DIMETHYL FUMARATE DR 240 MG CAPSULE DR [Tecfidera] |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
DIPENTUM 250 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | None |
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix] |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix] |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DIPHENOXYLATE-ATROP 2.5-0.025 TABLET [Vi-Atro] |
2* |
Generic |
$10.00 | $27.00 | None |
DIPHENOXYLATE/ATROPINE LIQ |
2* |
Generic |
$10.00 | $27.00 | None |
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DIPYRIDAMOLE 25 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DIPYRIDAMOLE 50 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DIPYRIDAMOLE 75 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DISOPYRAMIDE 100 MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT) |
2* |
Generic |
$10.00 | $27.00 | None |
DISULFIRAM 250 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DIURIL 250MG/5ML SUSPENSION ORAL |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | None |
DIVALPROEX DR 125 MG CAPSULE SPRNK |
2* |
Generic |
$10.00 | $27.00 | None |
DIVALPROEX SOD DR 125 MG TABLET DR [Depakote] |
2* |
Generic |
$10.00 | $27.00 | None |
DIVALPROEX SOD DR 250 MG TABLET DR [Depakote] |
2* |
Generic |
$10.00 | $27.00 | None |
DIVALPROEX SOD DR 500 MG TABLET DR [Depakote] |
2* |
Generic |
$10.00 | $27.00 | None |
DIVALPROEX SOD ER 250 MG TABLET 24H [Depakote ER] |
2* |
Generic |
$10.00 | $27.00 | None |
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER] |
2* |
Generic |
$10.00 | $27.00 | None |
DOFETILIDE 125 MCG CAPSULE [Tikosyn] |
2* |
Generic |
$10.00 | $27.00 | None |
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 | $27.00 | None |
DOFETILIDE 500 MCG CAPSULE [Tikosyn] |
2* |
Generic |
$10.00 | $27.00 | None |
DONEPEZIL HCL 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
DONEPEZIL HCL 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
DONEPEZIL HCL ODT 10 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DONEPEZIL HCL ODT 5 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt] |
2* |
Generic |
$10.00 | $27.00 | None |
DORZOLAMIDE-TIMOLOL EYE DROPS [Cosopt PF] |
2* |
Generic |
$10.00 | $27.00 | None |
DOVATO 50-300 MG TABLET |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura] |
2* |
Generic |
$10.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXEPIN 10 MG CAPSULE [Sinequan] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXEPIN 10 MG/ML ORAL CONC [Sinequan] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXEPIN 100 MG CAPSULE [Sinequan] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXEPIN 25 MG CAPSULE [Sinequan] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXEPIN 50 MG CAPSULE [Sinequan] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXEPIN 75MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | $27.00 | None |
DOXERCALCIFEROL 0.5 MCG CAPSULE [Hectorol] |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | P |
DOXERCALCIFEROL 1 MCG CAPSULE [Hectorol] |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DOXERCALCIFEROL 2.5 MCG CAPSULE [Hectorol] |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | P |
DOXY 100 VIAL |
4 |
Non-Preferred Drug |
$98.00 | $291.00 | None |
doxycycline 25 mg/5 ml susp |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYCYCLINE HYCLATE 100 MG CAPSULE [Vibramycin] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYCYCLINE HYCLATE 50 MG CAPSULE |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYCYCLINE MONO 100 MG CAPSULE [Monodox] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox] |
2* |
Generic |
$10.00 | $27.00 | None |
DOXYLAMINE-PYRIDOXINE 10-10 MG TABLET DR [Diclegis] |
2* |
Generic |
$10.00 | $27.00 | None |
DRONABINOL 10 MG CAPSULE [Marinol] |
2* |
Generic |
$10.00 | $27.00 | 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* |
Generic |
$10.00 | $27.00 | P Q:60 /30Days |
DRONABINOL 5 MG CAPSULE [Marinol] |
2* |
Generic |
$10.00 | $27.00 | P Q:60 /30Days |
DROSPIRENONE-EE 3-0.02 MG TABLET |
2* |
Generic |
$10.00 | $27.00 | None |
DROXIDOPA 100 MG CAPSULE [NORTHERA] |
2* |
Generic |
$10.00 | $27.00 | P |
DROXIDOPA 200 MG CAPSULE [NORTHERA] |
2* |
Generic |
$10.00 | $27.00 | P |
DROXIDOPA 300 MG CAPSULE [NORTHERA] |
2* |
Generic |
$10.00 | $27.00 | P |
DUAVEE 0.45-20 MG TABLET |
3 |
Preferred Brand |
$45.00 | $132.00 | None |
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta] |
2* |
Generic |
$10.00 | $27.00 | None |
DULOXETINE HCL DR 30 MG CAPSULE DR [Drizalma] |
2* |
Generic |
$10.00 | $27.00 | None |
DULOXETINE HCL DR 60 MG CAPSULE DR [Drizalma] |
2* |
Generic |
$10.00 | $27.00 | None |
DUPIXENT 100 MG/0.67 ML SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
DUPIXENT 200 MG/1.14 ML SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
DUPIXENT 300 MG/2 ML PEN INJECTOR |
5 |
Tier 5 |
25% | N/A | P |
DUPIXENT 300 MG/2 ML SAFE SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
DUTASTERIDE 0.5 MG CAPSULE [Avodart] |
2* |
Generic |
$10.00 | $27.00 | None |