Drug List - D

D
Drug Name Tier Restrictions
DALIRESP 3 Prior authorization
DANAZOL 2
DAPSONE 1
DDAVP 3 Prior authorization
DELESTROGEN INJ 3 Prior authorization
DELZICOL 2
DEMECLOCYCLINE 1
DENAVIR 2 Quantity limit
DENTA 5000 PLUS 1 Quantity limit
DENTAGEL 1 Quantity limit
DEPAKOTE 3
DEPAKOTE ER 3
DEPLIN 2
DEPO-MEDROL INJ 3 Prior authorization
DEPO-TESTOSTERONE INJ 200MG/ML 3
DERMA-SMOOTHE/FS 3 Prior authorization, Quantity limit, Step therapy
DERMAZENE 1 Quantity limit
DERMOTIC OIL 2
DESCOVY 2
DESIPRAMINE HCL 1
DESLORATADINE 1
DESMOPRESSINE ACETATE 1
DESOGEN-28 TAB 3 Prior authorization
DESONIDE 1 Quantity limit
DESOXIMETASONE 1 Quantity limit
DESVENLAFAX TAB ER 1
DETROL 3 Prior authorization
DETROL LA 3 Prior authorization
DEXAMETHASONE 1
DEXAMETHASONE SODIUM PHOSPH 1
DEXAMETHASONE SODIUM PHOSPH INJ 4MG/ML UD $0
DEXEDRINE 3 Prior authorization
DEXILANT NC
DEXMETHYLPHENIDATE HCL 1
DEXTROAMPHET CAP ER 1
DEXTROAMPHETAMINE CR 1
DEXTROAMPHETAMINE SULFATE 1
DEXTROSTAT 1
DIALYVITE 1
DIALYVITE 3000 2
DIAMOX 3 Travel, Prior authorization
DIASTAT 3 Prior authorization
DIATX ZN 3
DIAZEPAM 1
DICLEGIS 3 Prior authorization
DICLO/MISOPR TAB 75-0.2MG 1
DICLOFEN POT TAB 50MG 1
DICLOFENAC SODIUM 1
DICLOFENAC SODIUM ER 1
DICLOFENAC/MISOPROSTOL DR 1
DICLOXACILLIN 1
DICYCLOMINE HCL 1
DIDRONEL 1
DIETHYLPROPION HCL 1
DIETHYLPROPION HCL ER 1
DIFFERIN 3 Prior authorization, Quantity limit
DIFICID 3 Prior authorization
DIFLORASONE DIACETATE 1 Quantity limit
DIFLUNISAL 1
DIGOXIN 1
DIHYDROERGOTAMINE 1
DILANTIN 1
DILT-XR 1
DILTIAZEM 1
DILTIAZEM HCL 1
DILTZAC 1
DIOVAN 3 Prior authorizatoan
DIOVAN HCT 3 Prior authorization
DIPENTUM 2
DIPHENHYDRAM INJ 50MG/ML 1
DIPHENOXY/ATROP 1
DIPIVEFRIN HCL 1
DIPROLENE 3 Prior authorization, Quantity limit
DIPYRIDAMOLE 1
DISOPYRAMIDE PHOSPHATE 1
DISULFIRAM TAB 250MG 1
DITROPAN 3 Prior authorization
DITROPAN XL 3 Prior authorization
DIURIL 2
DIVALPROEX SODIUM 1
DIVIGEL GEL 1MG/GM 3
DOFETILIDE CAP 1
DOMEBORO 1
DONEPEZIL 1
DONNATAL 3
DORYX 3 Prior authorization, Step therapy
DORZOLAMIDE 1
DORZOLAMIDE HCL/TIMOLOL MAL 1
DOSTINEX 2 Prior authorization
DOVONEX CREAM 3 Prior authorization, Quantity limit
DOXAZOSIN MESYLATE 1
DOXEPIN HCL 1
DOXYCYCLINE HYC 1 Travel
DOXYCYCLINE MONO 1
DRITHO-SCALP 3 Prior authorization, Quantity limit
DRONABINOL 1
DROSPIR/ETHI TAB 3-0.03MG 1*
DRYSOL SOL 20% 2
DUAC CS KIT 3 Prior authorization, Quantity limit, Step therapy
DUET 3
DUET DHA PAK 3
DUETACT 3 Prior authorization
DUKE'S SOLUTION 1
DULERA 2
DULERA AER 2
DULOXETINE DR 1
DUPIXENT 3 Prior authorization, minimum age 18 or older
DURAGESIC DIS 3 Quantity limit
DUREZOL EMU 0.05% 3
DUTASTERIDE 1
DYAZIDE 3 Prior authorization
DYMISTA SPR 137-50 3
DYNACIN 3 Prior authorization
DYNACIRC 3 Prior authorization
DYRENIUM 3 Prior authorization