2026 Blue Rx PDP Complete (PDP) formulary (drug list)

Contract S5593, plan 003 · Pennsylvania · 3,788 drugs on file · formulary ID 00026017. Each drug links to its cost in every CMS PDP Region 06 plan.

220 drugs starting with M.

Drug name	Tier	30-day preferred pharmacy	90-day mail order	Usage management
M-M-R II 1000/12500/1000 [TCID_50]/.5mL Injection, Powder, Lyophilized, For SuspensionMeasles, Mumps, And Rubella Virus Vaccine Live	3Preferred Brand	25%	25%	None
MALATHION .0005 g/mL Lotion	4Non-Preferred Drug	25%	25%	None
MARAVIROC 150 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	None
MARAVIROC 300 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
MARLISSA KitLevonorgestrel And Ethinyl Estradiol	2Generic	$5.00	$12.50	None
MATULANE 50 mg CapsuleProcarbazine Hydrochloride	5Specialty Tier	25%	N/A	None
MATZIM LA 180 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	2Generic	$5.00	$12.50	None
MATZIM LA 240 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	2Generic	$5.00	$12.50	None
MATZIM LA 300 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	2Generic	$5.00	$12.50	None
MATZIM LA 360 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	2Generic	$5.00	$12.50	None
MATZIM LA 420 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	2Generic	$5.00	$12.50	None
MAVYRET 20/50 mg PelletGlecaprevir And Pibrentasvir	5Specialty Tier	25%	N/A	PA QL 14 per 28 days
MAVYRET 40/100 mg Tablet, Film CoatedGlecaprevir And Pibrentasvir	5Specialty Tier	25%	N/A	PA QL 84 per 28 days
MECLIZINE HYDROCHLORIDE 12.5 mg TabletMeclizine	2Generic	$5.00	$12.50	None
MECLIZINE HYDROCHLORIDE 25 mg Tablet	2Generic	$5.00	$12.50	None
MEDROL 2 mg TabletMethylprednisolone	4Non-Preferred Drug	25%	25%	None
MEDROXYPROGESTERONE ACETATE 10 mg Tablet	2Generic	$5.00	$12.50	None
MEDROXYPROGESTERONE ACETATE 150 mg/mL Injection, Suspension	2Generic	$5.00	$12.50	None
MEDROXYPROGESTERONE ACETATE 150 mg/mL Injection, Suspension	2Generic	$5.00	$12.50	None
MEDROXYPROGESTERONE ACETATE 2.5 mg Tablet	2Generic	$5.00	$12.50	None
MEDROXYPROGESTERONE ACETATE 5 mg Tablet	2Generic	$5.00	$12.50	None
MEFENAMIC ACID 250 mg Capsule	4Non-Preferred Drug	25%	25%	None
MEFLOQUINE HYDROCHLORIDE 250 mg Tablet	2Generic	$5.00	$12.50	None
MEGESTROL ACETATE 125 mg/mL Suspension	4Non-Preferred Drug	25%	25%	PA
MEGESTROL ACETATE 20 mg Tablet	2Generic	$5.00	$12.50	PA
MEGESTROL ACETATE 40 mg Tablet	2Generic	$5.00	$12.50	PA
MEGESTROL ACETATE 40 mg/mL Suspension	2Generic	$5.00	$12.50	PA
MEKINIST .05 mg/mL Powder, For SolutionTrametinib	5Specialty Tier	25%	N/A	PA QL 126 per 31 days
MEKINIST .5 mg Tablet, Film CoatedTrametinib	5Specialty Tier	25%	N/A	PA QL 93 per 31 days
MEKINIST 2 mg Tablet, Film CoatedTrametinib	5Specialty Tier	25%	N/A	PA QL 31 per 31 days
MEKTOVI 15 mg Tablet, Film CoatedBinimetinib	5Specialty Tier	25%	N/A	PA QL 186 per 31 days
MELOXICAM 15 mg Tablet	1Preferred Generic	$0.00	$0.00	None
MELOXICAM 7.5 mg Tablet	1Preferred Generic	$0.00	$0.00	None
MEMANTINE 2 mg/mL SolutionMemantine Hydrochloride	3Preferred Brand	25%	25%	None
MEMANTINE AND DONEPEZIL HYDROCHLORIDES 21/10 mg Capsule, Extended Release	4Non-Preferred Drug	25%	25%	PA
MEMANTINE AND DONEPEZIL HYDROCHLORIDES EXTENDED-RELEASE 14/10 mg Capsule, Extended ReleaseMemantine And Donepezil	4Non-Preferred Drug	25%	25%	PA
MEMANTINE AND DONEPEZIL HYDROCHLORIDES EXTENDED-RELEASE 28/10 mg Capsule, Extended ReleaseMemantine And Donepezil	4Non-Preferred Drug	25%	25%	PA
MEMANTINE HYDROCHLORIDE 10 mg Tablet	2Generic	$5.00	$12.50	None
MEMANTINE HYDROCHLORIDE 14 mg Capsule, Extended Release	3Preferred Brand	25%	25%	None
MEMANTINE HYDROCHLORIDE 21 mg Capsule, Extended Release	3Preferred Brand	25%	25%	None
MEMANTINE HYDROCHLORIDE 28 mg Capsule, Extended Release	3Preferred Brand	25%	25%	None
MEMANTINE HYDROCHLORIDE 5 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
MEMANTINE HYDROCHLORIDE 7 mg Capsule, Extended Release	3Preferred Brand	25%	25%	None
MEMANTINE HYDROCHLORIDE Kit	4Non-Preferred Drug	25%	25%	None
MENQUADFI 10/10/10/10 ug/.5mL Injection, SolutionNeisseria Meningitidis Group A Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen, Neisseria Meningitidis Group C Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen, Neisseria Meningitidis Group Y Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen, And Neisseria Meningitidis Group W-135 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen	4Non-Preferred Drug	25%	25%	None
MENVEO KitMeningococcal (Groups A, C, Y And W-135) Oligosaccharide Diphtheria Crm197 Conjugate Vaccine	3Preferred Brand	25%	25%	None
MERCAPTOPURINE 20 mg/mL Suspension	5Specialty Tier	25%	N/A	None
MERCAPTOPURINE 50 mg Tablet	2Generic	$5.00	$12.50	None
MEROPENEM 1 g Injection, Powder, For Solution	3Preferred Brand	25%	25%	None
MEROPENEM 500 mg Injection, Powder, For Solution	3Preferred Brand	25%	25%	None
MESALAMINE .375 g Capsule, Extended Release	4Non-Preferred Drug	25%	25%	QL 124 per 31 days
MESALAMINE 1.2 g Tablet, Delayed Release	3Preferred Brand	25%	25%	QL 124 per 31 days
MESALAMINE 4 g/60mL Enema	4Non-Preferred Drug	25%	25%	QL 186 per 31 days
MESALAMINE 400 mg Capsule, Delayed Release	3Preferred Brand	25%	25%	QL 186 per 31 days
MESALAMINE 500 mg Capsule, Extended Release	4Non-Preferred Drug	25%	25%	PA QL 248 per 31 days
MESNA 400 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
METAXALONE 400 mg Tablet	2Generic	$5.00	$12.50	PA
METAXALONE 800 mg Tablet	3Preferred Brand	25%	25%	PA
METFORMIN 500 mg Tablet, Extended ReleaseMetformin Er 500 Mg	1Preferred Generic	$0.00	$0.00	None
METFORMIN HYDROCHLORIDE 500 mg Tablet	1Preferred Generic	$0.00	$0.00	None
METFORMIN HYDROCHLORIDE 750 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
METFORMIN HYDROCHLORIDE 850 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METFORMIN HYDROCHLORIDE ORAL SOLUTION 500 mg/5mL SolutionMetformin Hydrochloride	4Non-Preferred Drug	25%	25%	ST QL 791 per 31 days
METHADONE HYDROCHLORIDE 10 mg Tablet	2Generic	$5.00	$12.50	PA QL 124 per 31 days
METHADONE HYDROCHLORIDE 10 mg/5mL Solution	2Generic	$5.00	$12.50	PA QL 62 per 31 days
METHADONE HYDROCHLORIDE 5 mg Tablet	2Generic	$5.00	$12.50	PA QL 248 per 31 days
METHADONE HYDROCHLORIDE 5 mg/5mL Solution	2Generic	$5.00	$12.50	PA QL 124 per 31 days
METHAZOLAMIDE 25 mg Tablet	2Generic	$5.00	$12.50	None
METHAZOLAMIDE 50 mg Tablet	2Generic	$5.00	$12.50	None
METHENAMINE HIPPURATE 1 g Tablet	2Generic	$5.00	$12.50	None
METHIMAZOLE 10 mg Tablet	2Generic	$5.00	$12.50	None
METHIMAZOLE 5 mg Tablet	2Generic	$5.00	$12.50	None
METHOTREXATE 2.5 mg Tablet	1Preferred Generic	$0.00	$0.00	PA
METHOTREXATE 25 mg/mL Injection, Solution	2Generic	$5.00	$12.50	PA
METHOTREXATE 25 mg/mL Solution	2Generic	$5.00	$12.50	PA
METHSCOPOLAMINE BROMIDE 2.5 mg Tablet	2Generic	$5.00	$12.50	None
METHSCOPOLAMINE BROMIDE 5 mg Tablet	2Generic	$5.00	$12.50	None
METHSUXIMIDE 300 mg Capsule	4Non-Preferred Drug	25%	25%	None
METHYLPHENIDATE 1.1 mg/h Patch	4Non-Preferred Drug	25%	25%	PA QL 3 per 30 days
METHYLPHENIDATE 1.6 mg/h Patch	4Non-Preferred Drug	25%	25%	PA QL 3 per 30 days
METHYLPHENIDATE 2.2 mg/h Patch	4Non-Preferred Drug	25%	25%	PA QL 3 per 30 days
METHYLPHENIDATE 3.3 mg/h Patch	4Non-Preferred Drug	25%	25%	PA QL 3 per 30 days
METHYLPHENIDATE HYDROCHLORIDE (LA) 60 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 10 mg Capsule, Extended Release	4Non-Preferred Drug	25%	25%	QL 186 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet	2Generic	$5.00	$12.50	QL 93 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet, Extended Release	2Generic	$5.00	$12.50	QL 93 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 18 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 20 mg Capsule, Extended Release	4Non-Preferred Drug	25%	25%	QL 93 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 20 mg Tablet	2Generic	$5.00	$12.50	QL 93 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 20 mg Tablet, Extended Release	2Generic	$5.00	$12.50	QL 93 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 27 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 30 mg Capsule, Extended Release	4Non-Preferred Drug	25%	25%	QL 62 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 36 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 40 mg Capsule, Extended Release	4Non-Preferred Drug	25%	25%	QL 62 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 5 mg Tablet	2Generic	$5.00	$12.50	QL 93 per 31 days
METHYLPHENIDATE HYDROCHLORIDE 54 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE CD 10 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE CD 20 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE CD 30 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE CD 40 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE CD 50 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPHENIDATE HYDROCHLORIDE CD 60 mg Capsule, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
METHYLPREDNISOLONE 16 mg Tablet	2Generic	$5.00	$12.50	None
METHYLPREDNISOLONE 32 mg Tablet	2Generic	$5.00	$12.50	None
METHYLPREDNISOLONE 4 mg Tablet	2Generic	$5.00	$12.50	None
METHYLPREDNISOLONE 4 mg Tablet	2Generic	$5.00	$12.50	None
METHYLPREDNISOLONE 8 mg Tablet	2Generic	$5.00	$12.50	None
METOCLOPRAMIDE 10 mg Tablet	2Generic	$5.00	$12.50	None
METOCLOPRAMIDE 5 mg Tablet	2Generic	$5.00	$12.50	None
METOCLOPRAMIDE 5 mg/5mL Solution	2Generic	$5.00	$12.50	None
METOLAZONE 10 mg Tablet	2Generic	$5.00	$12.50	None
METOLAZONE 2.5 mg Tablet	2Generic	$5.00	$12.50	None
METOLAZONE 5 mg Tablet	2Generic	$5.00	$12.50	None
METOPROLOL SUCCINATE 100 mg Tablet, Film Coated, Extended Release	1Preferred Generic	$0.00	$0.00	None
METOPROLOL SUCCINATE 200 mg Tablet, Film Coated, Extended Release	1Preferred Generic	$0.00	$0.00	None
METOPROLOL SUCCINATE 25 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
METOPROLOL SUCCINATE 50 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 100 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 25 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 37.5 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 50 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 75 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE 100/25 mg Tablet	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE 100/50 mg Tablet	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE 50/25 mg Tablet	1Preferred Generic	$0.00	$0.00	None
METRONIDAZOLE 10 mg/g Gel	1Preferred Generic	$0.00	$0.00	None
METRONIDAZOLE 250 mg Tablet	1Preferred Generic	$0.00	$0.00	None
METRONIDAZOLE 500 mg Tablet	1Preferred Generic	$0.00	$0.00	None
METRONIDAZOLE 500 mg/100mL Injection, Solution	2Generic	$5.00	$12.50	None
METRONIDAZOLE 7.5 mg/g Cream	2Generic	$5.00	$12.50	None
METRONIDAZOLE 7.5 mg/g Gel	2Generic	$5.00	$12.50	None
METRONIDAZOLE 7.5 mg/mL Lotion	2Generic	$5.00	$12.50	None
METRONIDAZOLE VAGINAL 7.5 mg/g GelMetronidazole	3Preferred Brand	25%	25%	None
METYROSINE 250 mg Capsule	5Specialty Tier	25%	N/A	PA
MEXILETINE HYDROCHLORIDE 150 mg Capsule	3Preferred Brand	25%	25%	None
MEXILETINE HYDROCHLORIDE 200 mg Capsule	3Preferred Brand	25%	25%	None
MEXILETINE HYDROCHLORIDE 250 mg Capsule	3Preferred Brand	25%	25%	None
MICAFUNGIN 100 mg Injection, Powder, Lyophilized, For SolutionMicafungin Sodium	4Non-Preferred Drug	25%	25%	None
MICAFUNGIN 50 mg Injection, Powder, Lyophilized, For SolutionMicafungin Sodium	4Non-Preferred Drug	25%	25%	None
MICONAZOLE NITRATE 200 mg Suppository	2Generic	$5.00	$12.50	None
MICROGESTIN 1.5/30 KitNorethindrone Acetate/Ethinyl Estradiol	2Generic	$5.00	$12.50	None
MICROGESTIN 1/20 KitNorethindrone Acetate/Ethinyl Estradiol	2Generic	$5.00	$12.50	None
MICROGESTIN FE 1.5/30 KitNorethindrone Acetate/Ethinyl Estradiol And Ferrous Fumarate	2Generic	$5.00	$12.50	None
MICROGESTIN FE 1/20 KitNorethindrone Acetate/Ethinyl Estradiol And Ferrous Fumarate	2Generic	$5.00	$12.50	None
MIDODRINE HYDROCHLORIDE 10 mg Tablet	2Generic	$5.00	$12.50	None
MIDODRINE HYDROCHLORIDE 2.5 mg Tablet	2Generic	$5.00	$12.50	None
MIDODRINE HYDROCHLORIDE 5 mg Tablet	2Generic	$5.00	$12.50	None
MIFEPRISTONE 300 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	PA QL 124 per 31 days
MIGLITOL 100 mg Tablet, Coated	2Generic	$5.00	$12.50	None
MIGLITOL 25 mg Tablet, Coated	2Generic	$5.00	$12.50	None
MIGLITOL 50 mg Tablet, Coated	2Generic	$5.00	$12.50	None
MIGLUSTAT 100 mg Capsule	5Specialty Tier	25%	N/A	PA QL 93 per 31 days
MILI KitNorgestimate And Ethinyl Estradiol	2Generic	$5.00	$12.50	None
MINOCYCLINE HYDROCHLORIDE 100 mg Capsule	2Generic	$5.00	$12.50	None
MINOCYCLINE HYDROCHLORIDE 100 mg Tablet	2Generic	$5.00	$12.50	None
MINOCYCLINE HYDROCHLORIDE 50 mg Capsule	2Generic	$5.00	$12.50	None
MINOCYCLINE HYDROCHLORIDE 50 mg Tablet	2Generic	$5.00	$12.50	None
MINOCYCLINE HYDROCHLORIDE 75 mg Capsule	2Generic	$5.00	$12.50	None
MINOCYCLINE HYDROCHLORIDE 75 mg Tablet	2Generic	$5.00	$12.50	None
MINOXIDIL 10 mg Tablet	2Generic	$5.00	$12.50	None
MINOXIDIL 2.5 mg Tablet	2Generic	$5.00	$12.50	None
MIRTAZAPINE 15 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
MIRTAZAPINE 15 mg Tablet, Orally Disintegrating	3Preferred Brand	25%	25%	None
MIRTAZAPINE 30 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
MIRTAZAPINE 30 mg Tablet, Orally Disintegrating	3Preferred Brand	25%	25%	None
MIRTAZAPINE 45 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
MIRTAZAPINE 45 mg Tablet, Orally Disintegrating	3Preferred Brand	25%	25%	None
MIRTAZAPINE 7.5 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
MISOPROSTOL 100 ug Tablet	2Generic	$5.00	$12.50	None
MISOPROSTOL 200 ug Tablet	2Generic	$5.00	$12.50	None
MIXED SALTS OF A SINGLE ENTITY AMPHETAMINE PRODUCT XR 2.5/2.5/2.5/2.5 mg Capsule, Extended ReleaseDextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate	3Preferred Brand	25%	25%	QL 31 per 31 days
MIXED SALTS OF A SINGLE ENTITY AMPHETAMINE PRODUCT XR 5/5/5/5 mg Capsule, Extended ReleaseDextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate	3Preferred Brand	25%	25%	QL 31 per 31 days
MODAFINIL 100 mg Tablet	2Generic	$5.00	$12.50	PA QL 31 per 31 days
MODAFINIL 200 mg Tablet	2Generic	$5.00	$12.50	PA QL 31 per 31 days
MODEYSO 125 mg CapsuleDordaviprone	5Specialty Tier	25%	N/A	PA QL 2 per 28 days
MOEXIPRIL HYDROCHLORIDE 15 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
MOEXIPRIL HYDROCHLORIDE 7.5 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
MOLINDONE HYDROCHLORIDE 10 mg Tablet	4Non-Preferred Drug	25%	25%	None
MOLINDONE HYDROCHLORIDE 25 mg Tablet	4Non-Preferred Drug	25%	25%	None
MOLINDONE HYDROCHLORIDE 5 mg Tablet	4Non-Preferred Drug	25%	25%	None
MOMETASONE FUROATE 1 mg/g Cream	2Generic	$5.00	$12.50	None
MOMETASONE FUROATE 1 mg/g Ointment	2Generic	$5.00	$12.50	None
MOMETASONE FUROATE 1 mg/mL Solution	2Generic	$5.00	$12.50	None
MOMETASONE FUROATE 50 ug Spray, Metered	3Preferred Brand	25%	25%	QL 34 per 30 days
MONTELUKAST SODIUM 10 mg Tablet, Film Coated	2Generic	$5.00	$12.50	QL 31 per 31 days
MONTELUKAST SODIUM 4 mg Tablet, Chewable	2Generic	$5.00	$12.50	QL 31 per 31 days
MONTELUKAST SODIUM 5 mg Tablet, Chewable	2Generic	$5.00	$12.50	QL 31 per 31 days
MORPHINE SULFATE 15 mg Tablet	2Generic	$5.00	$12.50	PA QL 186 per 31 days
MORPHINE SULFATE 20 mg/5mL Solution	2Generic	$5.00	$12.50	PA QL 14 per 31 days
MORPHINE SULFATE 20 mg/mL Solution	2Generic	$5.00	$12.50	PA QL 31 per 31 days
MORPHINE SULFATE 30 mg Tablet	2Generic	$5.00	$12.50	PA QL 186 per 31 days
MORPHINE SULFATE EXTENDED RELEASE 100 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	25%	25%	PA QL 62 per 31 days
MORPHINE SULFATE EXTENDED RELEASE 15 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	25%	25%	PA QL 1 per 31 days
MORPHINE SULFATE EXTENDED RELEASE 200 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	25%	25%	PA QL 31 per 31 days
MORPHINE SULFATE EXTENDED RELEASE 30 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	25%	25%	PA QL 1 per 31 days
MORPHINE SULFATE EXTENDED RELEASE 60 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	25%	25%	PA QL 1 per 31 days
MOUNJARO 10 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	25%	25%	PA QL 2 per 28 days
MOUNJARO 12.5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	25%	25%	PA QL 2 per 28 days
MOUNJARO 15 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	25%	25%	PA QL 2 per 28 days
MOUNJARO 2.5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	25%	25%	PA QL 2 per 28 days
MOUNJARO 5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	25%	25%	PA QL 2 per 28 days
MOUNJARO 7.5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	25%	25%	PA QL 2 per 28 days
MOVANTIK 12.5 mg Tablet, Film CoatedNaloxegol Oxalate	3Preferred Brand	25%	25%	QL 31 per 31 days
MOVANTIK 25 mg Tablet, Film CoatedNaloxegol Oxalate	3Preferred Brand	25%	25%	QL 31 per 31 days
MOXIFLOXACIN 400 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
MOXIFLOXACIN 5 mg/mL Solution/ Drops	3Preferred Brand	25%	25%	None
MOXIFLOXACIN HYDROCHLORIDE 400 mg/250mL Injection, Solution	4Non-Preferred Drug	25%	25%	None
MRESVIA 50 ug/.5mL SuspensionRespiratory Syncytial Virus Vaccine	3Preferred Brand	25%	25%	QL 1 per 365 days
MULPLETA 3 mg Tablet, Film CoatedLusutrombopag	5Specialty Tier	25%	N/A	PA
MULTAQ 400 mg Tablet, Film CoatedDronedarone	4Non-Preferred Drug	25%	25%	None
MUPIROCIN 20 mg/g Ointment	2Generic	$5.00	$12.50	None
MYCOPHENOLATE MOFETIL 200 mg/mL Powder, For Suspension	5Specialty Tier	25%	N/A	PA
MYCOPHENOLATE MOFETIL 250 mg Capsule	2Generic	$5.00	$12.50	PA
MYCOPHENOLATE MOFETIL 500 mg Tablet, Film Coated	2Generic	$5.00	$12.50	PA
MYCOPHENOLIC ACID 180 mg Tablet, Delayed Release	2Generic	$5.00	$12.50	PA
MYCOPHENOLIC ACID 360 mg Tablet, Delayed Release	2Generic	$5.00	$12.50	PA
MYRBETRIQ 25 mg Tablet, Film Coated, Extended ReleaseMirabegron	3Preferred Brand	25%	25%	QL 31 per 31 days
MYRBETRIQ 50 mg Tablet, Film Coated, Extended ReleaseMirabegron	3Preferred Brand	25%	25%	QL 31 per 31 days
MYRBETRIQ 8 mg/mL Granule, For Suspension, Extended ReleaseMirabegron	3Preferred Brand	25%	25%	QL 3 per 30 days
MYTESI 125 mg Tablet, CoatedCrofelemer	5Specialty Tier	25%	N/A	QL 62 per 31 days

PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.