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2024 Medicare Part D and Medicare Advantage Plan Formulary Browser

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AARP Medicare Rx Walgreens from UHC (PDP) (S5921-411-0)
Tier 1 (245)
Tier 2 (488)
Tier 3 (794)
Tier 4 (1139)
Tier 5 (668)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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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 
2024 Medicare Part D Plan Formulary Information
AARP Medicare Rx Walgreens from UHC (PDP) (S5921-411-0)
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 AARP Medicare Rx Walgreens from UHC (PDP) (S5921-411-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 30 which includes: OR WA
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]   3 Preferred Brand $40.00$120.00Q:60
/30Days
DANAZOL 100 MG CAPSULE [Danocrine]   4 Non-Preferred Drug 50%50%None
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 50%50%None
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 50%50%None
DAPSONE 100 MG TABLET   3 Preferred Brand $40.00$120.00None
DAPSONE 25 MG TABLET   3 Preferred Brand $40.00$120.00None
DAPTACEL DTAP VACCINE VIAL   3 Preferred Brand $40.00$120.00Q:0.50
/1Days
DAPTOMYCIN 500 MG VIAL [Cubicin RF]   4 Non-Preferred Drug 50%50%None
DARUNAVIR 600 MG TABLET [Prezista]   5 Specialty Tier 27%N/AQ:60
/30Days
DARUNAVIR 800 MG TABLET [Prezista]   5 Specialty Tier 27%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DAURISMO 100 MG TABLET   5 Specialty Tier 27%N/AP Q:30
/30Days
DAURISMO 25 MG TABLET   5 Specialty Tier 27%N/AP Q:60
/30Days
DEBLITANE 0.35 MG TABLET   4 Non-Preferred Drug 50%50%None
DEFERASIROX 125 MG TB FOR SUSPENSION TABLET DISPER [Exjade]   4 Non-Preferred Drug 50%50%P
DEFERASIROX 180 MG GRANULE PACK [Jadenu]   5 Specialty Tier 27%N/AP
DEFERASIROX 180 MG TABLET [Jadenu]   3 Preferred Brand $40.00$120.00P
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 27%N/AP
DEFERASIROX 360 MG GRANULE PACK [Jadenu]   5 Specialty Tier 27%N/AP
DEFERASIROX 360 MG TABLET [Jadenu]   3 Preferred Brand $40.00$120.00P
DEFERASIROX 500 MG TB FOR SUSPENSION TABLET DISPER [Exjade]   5 Specialty Tier 27%N/AP
DEFERASIROX 90 MG GRANULE PACK [Jadenu]   5 Specialty Tier 27%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEFERASIROX 90 MG TABLET [Jadenu]   3 Preferred Brand $40.00$120.00P
DELSTRIGO 100-300-300 MG TABLET   5 Specialty Tier 27%N/AQ:30
/30Days
DEMECLOCYCLINE 150 MG TABLET [Declomycin]   4 Non-Preferred Drug 50%50%None
DEMECLOCYCLINE 300 MG TABLET [Declomycin]   4 Non-Preferred Drug 50%50%None
Depo-SubQ Provera 104mg/0.65mL 0.65 mL in 1 SYRINGE   4 Non-Preferred Drug 50%50%None
DESCOVY 120-15 MG TABLET   5 Specialty Tier 27%N/AQ:30
/30Days
DESCOVY 200-25 MG TABLET   5 Specialty Tier 27%N/AQ:30
/30Days
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
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 $40.00$120.00None
DESIPRAMINE 75 MG TABLET [Norpramin]   3 Preferred Brand $40.00$120.00None
DESMOPRESSIN 0.01% SOLUTION SPRAY/PUMP [Minirin]   4 Non-Preferred Drug 50%50%None
DESMOPRESSIN ACETATE 0.1 MG TABLET [DDAVP]   3 Preferred Brand $40.00$120.00None
DESMOPRESSIN ACETATE 0.2 MG TABLET [DDAVP]   3 Preferred Brand $40.00$120.00None
DESOGESTR-ETH ESTRAD ETH ESTRA TABLET [Volnea]   4 Non-Preferred Drug 50%50%None
DESOGESTREL-EE 0.15-0.03 MG TABLET [Solia]   4 Non-Preferred Drug 50%50%None
DESONIDE 0.05% OINTMENT [Tridesilon]   4 Non-Preferred Drug 50%50%Q:120
/30Days
DESOXIMETASONE 0.05% CREAM (G) [Topicort LP]   4 Non-Preferred Drug 50%50%Q:100
/30Days
DESOXIMETASONE 0.25% CREAM (G) [Topicort]   4 Non-Preferred Drug 50%50%Q:100
/30Days
DESVENLAFAXINE SUCCNT ER 100MG TABLET 24H [Pristiq]   3 Preferred Brand $40.00$120.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESVENLAFAXINE SUCCNT ER 25 MG TABLET 24H [Pristiq]   3 Preferred Brand $40.00$120.00Q:30
/30Days
DESVENLAFAXINE SUCCNT ER 50 MG TABLET 24H [Pristiq]   3 Preferred Brand $40.00$120.00Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   3 Preferred Brand $40.00$120.00None
DEXAMETHASONE 0.5 MG/5 ML LIQ SOLUTION   4 Non-Preferred Drug 50%50%None
DEXAMETHASONE 0.5MG TABLET   2 Generic $8.00$24.00None
DEXAMETHASONE 0.75MG TABLET   2 Generic $8.00$24.00None
DEXAMETHASONE 1.5MG TABLET   2 Generic $8.00$24.00None
DEXAMETHASONE 1MG TABLET   2 Generic $8.00$24.00None
DEXAMETHASONE 2MG TABLET   2 Generic $8.00$24.00None
DEXAMETHASONE 4MG TABLET   2 Generic $8.00$24.00None
DEXAMETHASONE 6MG TABLET   2 Generic $8.00$24.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXLANSOPRAZOLE DR 30 MG CAPSULE DR BP [Kapidex]   4 Non-Preferred Drug 50%50%Q:30
/30Days
DEXLANSOPRAZOLE DR 60 MG CAPSULE DR BP [Kapidex]   4 Non-Preferred Drug 50%50%Q:30
/30Days
DEXMETHYLPHENIDATE 10 MG TABLET [Focalin]   3 Preferred Brand $40.00$120.00Q:60
/30Days
DEXMETHYLPHENIDATE 2.5 MG TABLET [Focalin]   3 Preferred Brand $40.00$120.00Q:60
/30Days
DEXMETHYLPHENIDATE 5 MG TABLET [Focalin]   3 Preferred Brand $40.00$120.00Q:60
/30Days
DEXMETHYLPHENIDATE ER 10 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXMETHYLPHENIDATE ER 15 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXMETHYLPHENIDATE ER 20 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXMETHYLPHENIDATE ER 25 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXMETHYLPHENIDATE ER 30 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXMETHYLPHENIDATE ER 35 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXMETHYLPHENIDATE ER 40 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXMETHYLPHENIDATE ER 5 MG CAPSULE CPBP 50-50 [Focalin XR]   4 Non-Preferred Drug 50%50%None
DEXTROAMP-AMPHET ER 10 MG CAPSULE 24H [Adderall XR]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DEXTROAMP-AMPHET ER 15 MG CAPSULE 24H [Adderall XR]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DEXTROAMP-AMPHET ER 20 MG CAPSULE 24H [Adderall XR]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DEXTROAMP-AMPHET ER 25 MG CAPSULE 24H [Mydayis]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DEXTROAMP-AMPHET ER 30 MG CAPSULE 24H [Adderall XR]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DEXTROAMP-AMPHET ER 5 MG CAPSULE 24H [Adderall XR]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DEXTROAMP-AMPHETAMIN 20 MG TABLET   3 Preferred Brand $40.00$120.00Q:90
/30Days
DEXTROAMP-AMPHETAMIN 30 MG TABLET   3 Preferred Brand $40.00$120.00Q:60
/30Days
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi]   3 Preferred Brand $40.00$120.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMPHETAMINE 15 MG TABLET [Zenzedi]   3 Preferred Brand $40.00$120.00Q:90
/30Days
DEXTROAMPHETAMINE 20 MG TABLET [Zenzedi]   3 Preferred Brand $40.00$120.00Q:90
/30Days
DEXTROAMPHETAMINE 30 MG TABLET [Zenzedi]   3 Preferred Brand $40.00$120.00Q:60
/30Days
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi]   3 Preferred Brand $40.00$120.00Q:180
/30Days
DEXTROAMPHETAMINE ER 10 MG CAPSULE [Dexedrine Spansule]   4 Non-Preferred Drug 50%50%Q:180
/30Days
DEXTROAMPHETAMINE ER 15 MG CAPSULE [Dexedrine Spansule]   4 Non-Preferred Drug 50%50%Q:120
/30Days
DEXTROAMPHETAMINE ER 5 MG CAPSULE [Dexedrine Spansule]   4 Non-Preferred Drug 50%50%Q:90
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   3 Preferred Brand $40.00$120.00Q:60
/30Days
DEXTROSE 10%-1/4NS IV TUBEX   4 Non-Preferred Drug 50%50%None
DEXTROSE 10%-WATER IV SOLUTION   4 Non-Preferred Drug 50%50%None
DEXTROSE 2.5%-1/2NS IV SOLUTION   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE 5%-0.2% NACL IV SOLUTION   4 Non-Preferred Drug 50%50%None
DEXTROSE 5%-0.45% NACL IV SOLUTION   4 Non-Preferred Drug 50%50%None
DEXTROSE 5%-0.9% NACL IV SOLUTION   4 Non-Preferred Drug 50%50%P
DEXTROSE 5%-WATER IV SOLUTION PGY VL PRT   4 Non-Preferred Drug 50%50%P
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Drug 50%50%None
DIACOMIT 250 MG CAPSULE   5 Specialty Tier 27%N/AQ:360
/30Days
DIACOMIT 250 MG POWDER PACK   5 Specialty Tier 27%N/AQ:360
/30Days
DIACOMIT 500 MG CAPSULE   5 Specialty Tier 27%N/AQ:180
/30Days
DIACOMIT 500 MG POWDER PACK   5 Specialty Tier 27%N/AQ:180
/30Days
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat]   4 Non-Preferred Drug 50%50%Q:5
/30Days
DIAZEPAM 10 MG TABLET [Valium]   2 Generic $8.00$24.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIAZEPAM 2 MG TABLET [Valium]   2 Generic $8.00$24.00Q:120
/30Days
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat]   4 Non-Preferred Drug 50%50%Q:5
/30Days
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat]   4 Non-Preferred Drug 50%50%Q:5
/30Days
DIAZEPAM 5 MG TABLET [Valium]   2 Generic $8.00$24.00Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   4 Non-Preferred Drug 50%50%None
DIAZEPAM 5 MG/ML ORAL CONC   4 Non-Preferred Drug 50%50%Q:240
/30Days
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem]   4 Non-Preferred Drug 50%50%None
DICLOFENAC 0.1% EYE DROPS [Voltaren Ophthalmic]   2 Generic $8.00$24.00None
DICLOFENAC POT 50 MG TABLET [Cataflam]   3 Preferred Brand $40.00$120.00None
DICLOFENAC SOD EC 25 MG TABLET   3 Preferred Brand $40.00$120.00None
DICLOFENAC SOD EC 50 MG TABLET   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC SOD EC 75 MG TABLET   3 Preferred Brand $40.00$120.00None
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR]   3 Preferred Brand $40.00$120.00None
DICLOFENAC SODIUM 1% GEL [Voltaren Gel]   3 Preferred Brand $40.00$120.00None
DICLOFENAC SODIUM 3% GEL [Solaraze]   4 Non-Preferred Drug 50%50%P Q:100
/30Days
DICLOXACILLIN 250MG CAPSULE   3 Preferred Brand $40.00$120.00None
DICLOXACILLIN SODIUM 500MG CAPSULE   3 Preferred Brand $40.00$120.00None
DICYCLOMINE 10 MG CAPSULE [Bentyl]   2 Generic $8.00$24.00None
DICYCLOMINE 20 MG TABLET [Bentyl]   2 Generic $8.00$24.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   2 Generic $8.00$24.00None
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 50%50%None
DIFICID 40 MG/ML ORAL SUSPENSION   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   4 Non-Preferred Drug 50%50%None
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $8.00$24.00None
DIGOXIN 250 MCG TABLET [Lanoxin]   2 Generic $8.00$24.00None
DIHYDROERGOTAMINE 4 MG/ML SPRAY/PUMP [TRUDHESA]   5 Specialty Tier 27%N/AP Q:16
/28Days
DILANTIN 50MG INFATAB   3 Preferred Brand $40.00$120.00None
DILANTIN CAPSULES 30 MG ER   2 Generic $8.00$24.00None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   2 Generic $8.00$24.00None
DILT XR 120 MG CAPSULE   2 Generic $8.00$24.00None
DILT XR 180 MG CAPSULE   2 Generic $8.00$24.00None
DILT XR 240 MG CAPSULE   2 Generic $8.00$24.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $8.00$24.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 24H ER(CD) 120 MG CAPSULE ER 24H [Tiazac]   2 Generic $8.00$24.00None
DILTIAZEM 24H ER(CD) 180 MG CAPSULE ER 24H [Tiazac]   2 Generic $8.00$24.00None
DILTIAZEM 24H ER(CD) 240 MG CAPSULE ER 24H [Tiazac]   2 Generic $8.00$24.00None
DILTIAZEM 24H ER(CD) 300 MG CAPSULE ER 24H [Tiazac]   2 Generic $8.00$24.00None
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac]   2 Generic $8.00$24.00None
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac]   2 Generic $8.00$24.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $8.00$24.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $8.00$24.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $8.00$24.00None
DIMETHYL FUMARATE 30D START PK CAPSULE DR [Tecfidera]   4 Non-Preferred Drug 50%50%Q:120
/365Days
DIMETHYL FUMARATE DR 120 MG CAPSULE DR [Tecfidera]   4 Non-Preferred Drug 50%50%Q:56
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIMETHYL FUMARATE DR 240 MG CAPSULE DR [Tecfidera]   4 Non-Preferred Drug 50%50%Q:60
/30Days
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $40.00$120.00Q:0.50
/1Days
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $40.00$120.00Q:0.50
/1Days
DIPHENOXYLATE-ATROP 2.5-0.025 TABLET [Vi-Atro]   3 Preferred Brand $40.00$120.00None
DIPHENOXYLATE/ATROPINE LIQ   4 Non-Preferred Drug 50%50%None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $40.00$120.00Q:0.50
/1Days
DISULFIRAM 250 MG TABLET   4 Non-Preferred Drug 50%50%None
DISULFIRAM 500 MG TABLET [Antabuse]   4 Non-Preferred Drug 50%50%None
DIVALPROEX DR 125 MG CAPSULE SPRNK   2 Generic $8.00$24.00None
DIVALPROEX SOD DR 125 MG TABLET DR [Depakote]   2 Generic $8.00$24.00None
DIVALPROEX SOD DR 250 MG TABLET DR [Depakote]   2 Generic $8.00$24.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIVALPROEX SOD DR 500 MG TABLET DR [Depakote]   2 Generic $8.00$24.00None
DIVALPROEX SOD ER 250 MG TABLET 24H [Depakote ER]   3 Preferred Brand $40.00$120.00None
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER]   3 Preferred Brand $40.00$120.00None
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 50%50%Q:180
/30Days
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 50%50%Q:60
/30Days
DOLISHALE 90-20 MCG TABLET [Lybrel]   4 Non-Preferred Drug 50%50%None
DONEPEZIL HCL 10 MG TABLET   2 Generic $8.00$24.00Q:60
/30Days
DONEPEZIL HCL 23 MG TABLET [Aricept]   2 Generic $8.00$24.00Q:30
/30Days
DONEPEZIL HCL 5 MG TABLET   2 Generic $8.00$24.00Q:30
/30Days
DONEPEZIL HCL ODT 10 MG TABLET   2 Generic $8.00$24.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DONEPEZIL HCL ODT 5 MG TABLET   2 Generic $8.00$24.00Q:30
/30Days
DOPTELET 20 MG (30 TABLET PK)   5 Specialty Tier 27%N/AP Q:90
/30Days
DOPTELET 20 MG TABLET   5 Specialty Tier 27%N/AP Q:90
/30Days
DOPTELET 20 MG TABLET   5 Specialty Tier 27%N/AP Q:90
/30Days
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt]   2 Generic $8.00$24.00None
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF]   4 Non-Preferred Drug 50%50%None
DORZOLAMIDE-TIMOLOL EYE DROPS [Cosopt PF]   2 Generic $8.00$24.00None
DOVATO 50-300 MG TABLET   5 Specialty Tier 27%N/AQ:30
/30Days
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura]   2 Generic $8.00$24.00None
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura]   2 Generic $8.00$24.00None
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura]   2 Generic $8.00$24.00None
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 $8.00$24.00None
DOXEPIN 10 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 50%50%None
DOXEPIN 10 MG/ML ORAL CONC [Sinequan]   4 Non-Preferred Drug 50%50%None
DOXEPIN 100 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 50%50%None
DOXEPIN 25 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 50%50%None
DOXEPIN 5% CREAM (G) [Zonalon]   4 Non-Preferred Drug 50%50%P Q:90
/30Days
DOXEPIN 50 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 50%50%None
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 50%50%None
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
DOXY 100 VIAL   4 Non-Preferred Drug 50%50%None
doxycycline 25 mg/5 ml susp   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 100 MG CAPSULE [Vibramycin]   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs]   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE HYCLATE 50 MG CAPSULE   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE MONO 100 MG CAPSULE [Monodox]   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE MONO 100 MG TABLET   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox]   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE MONO 50 MG TABLET   3 Preferred Brand $40.00$120.00None
DOXYCYCLINE MONO 75 MG TABLET   3 Preferred Brand $40.00$120.00None
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 50%50%P
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 50%50%P
DROSPIRENONE-EE 3-0.02 MG TABLET   4 Non-Preferred Drug 50%50%None
DROSPIRENONE-EE 3-0.03 MG TABLET [Zumandimine]   4 Non-Preferred Drug 50%50%None
DROXIA 200MG CAPSULE   3 Preferred Brand $40.00$120.00None
DROXIA 300MG CAPSULE   3 Preferred Brand $40.00$120.00None
DROXIA 400MG CAPSULE   3 Preferred Brand $40.00$120.00None
DROXIDOPA 100 MG CAPSULE [NORTHERA]   4 Non-Preferred Drug 50%50%P Q:90
/30Days
DROXIDOPA 200 MG CAPSULE [NORTHERA]   4 Non-Preferred Drug 50%50%P Q:180
/30Days
DROXIDOPA 300 MG CAPSULE [NORTHERA]   4 Non-Preferred Drug 50%50%P Q:180
/30Days
DULERA 100 MCG-5 MCG INHALER HFA AER AD   4 Non-Preferred Drug 50%50%Q:13
/30Days
DULERA 200 MCG-5 MCG INHALER HFA AER AD   4 Non-Preferred Drug 50%50%Q:13
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DULERA 50 MCG-5 MCG INHALER HFA AER AD   4 Non-Preferred Drug 50%50%Q:13
/30Days
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta]   2 Generic $8.00$24.00Q:120
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Drizalma]   2 Generic $8.00$24.00Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Drizalma]   2 Generic $8.00$24.00Q:60
/30Days
DUPIXENT 100 MG/0.67 ML SYRINGE   5 Specialty Tier 27%N/AP Q:1.34
/28Days
DUPIXENT 200 MG/1.14 ML PEN INJCTR   5 Specialty Tier 27%N/AP Q:4.56
/28Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 27%N/AP Q:4.56
/28Days
DUPIXENT 300 MG/2 ML PEN INJECTOR   5 Specialty Tier 27%N/AP Q:8
/28Days
DUPIXENT 300 MG/2 ML SAFE SYRINGE   5 Specialty Tier 27%N/AP Q:8
/28Days
DUTASTERIDE 0.5 MG CAPSULE [Avodart]   2 Generic $8.00$24.00Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2024 Medicare Part D AARP Medicare Rx Walgreens from UHC (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 $545 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 $5,030) 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.

      *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. Please contact the drug plan for more details.

    • 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 June 2024)

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
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.