2009 Medicare Part D Plan Formulary Information |
BravoRx (S5998-024-0)
Benefit Details
|
The BravoRx (S5998-024-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 19 which includes: AR
|
Drugs Starting with Letter M
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
25% | 25% | None |
MACRODANTIN 25MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR |
2 |
Tier 2 |
25% | 25% | None |
MALARONE 250-100MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MALARONE 62.5-25MG PED TABLET |
2 |
Tier 2 |
25% | 25% | None |
MAPROTILINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MAPROTILINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MAPROTILINE 75MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MARGESIC H 5MG-500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MARINOL 10MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARINOL 2.5MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
MARINOL 5MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
MARPLAN 10MG TABLET (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
MATULANE 50MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
MAXIPIME 1G VIAL |
2 |
Tier 2 |
25% | 25% | None |
MAXIPIME 2G ADD-VANTAGE VL |
2 |
Tier 2 |
25% | 25% | None |
MAXIPIME 2G VIAL |
2 |
Tier 2 |
25% | 25% | None |
MAXIPIME 500MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
MECLIZINE HCL 12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MECLIZINE HCL 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLOFENAMATE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
25% | 25% | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
25% | 25% | None |
MEFOXIN 10GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
MEFOXIN 1GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
MEFOXIN 1GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
MEFOXIN 1GM/50ML PIGGYBACK |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEFOXIN 2GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
MEFOXIN 2GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
MEFOXIN 2GM/50ML PIGGYBACK |
2 |
Tier 2 |
25% | 25% | None |
MEGACE ES 625MG/5ML SUSP |
2 |
Tier 2 |
25% | 25% | None |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
1 |
Tier 1 |
25% | 25% | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
25% | 25% | None |
MELOXICAM 15MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
MELOXICAM 7.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
25% | 25% | None |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.3MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /90Days |
MENEST 0.625MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /90Days |
MENEST 1.25MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /90Days |
MENEST 2.5MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /90Days |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Tier 2 |
25% | 25% | None |
MENOSTAR 14 MCG/DAY PATCH |
2 |
Tier 2 |
25% | 25% | Q:12 /90Days |
MEPERIDINE 10MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | None |
MEPERIDINE 25MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
MEPERIDINE 50MG/5ML SYRUP |
1 |
Tier 1 |
25% | 25% | None |
MEPERIDINE 50MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
MEPERIDINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEPERIDINE HCL INJECTION 75MG 25 X 1ML VIALSD |
2 |
Tier 2 |
25% | 25% | None |
MEPERIDINE HCL TABLET 100MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
MEPERITAB 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEPERITAB 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEPRON 750MG/5ML ORAL SUSP |
2 |
Tier 2 |
25% | 25% | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MERUVAX II VACCINE/DILUENT |
2 |
Tier 2 |
25% | 25% | None |
MESALAMINE 4G/60ML ENEMA |
1 |
Tier 1 |
25% | 25% | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
1 |
Tier 1 |
25% | 25% | None |
MESNEX 400MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MESTINON 180MG TIMESPAN |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESTINON 60MG/5ML SYRUP |
2 |
Tier 2 |
25% | 25% | None |
METADATE CD 10MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
METADATE CD 20MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
METADATE CD 30MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
METADATE CD 40MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
METADATE CD 50MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
METADATE CD 60MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
METADATE ER 20MG TABLET SA |
1 |
Tier 1 |
25% | 25% | P |
METAPROTERENOL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METAPROTERENOL 10MG/5ML SYR |
1 |
Tier 1 |
25% | 25% | None |
METAPROTERENOL 20MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL SULFATE 0.4% 25 X 2.5ML CRTN |
1 |
Tier 1 |
25% | 25% | P |
METAPROTERENOL SULFATE SOLUTION 0.6% 25 X 2.5ML CRTN |
1 |
Tier 1 |
25% | 25% | P |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:180 /90Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:360 /90Days |
METFORMIN HCL 850MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:360 /90Days |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | Q:360 /90Days |
METFORMIN HCL ER 750MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:180 /90Days |
METHADONE 10MG/5ML SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
METHADONE 5MG/5ML SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
METHADONE HCL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT |
1 |
Tier 1 |
25% | 25% | None |
METHADONE INJ 10MG/ML |
1 |
Tier 1 |
25% | 25% | None |
METHADOSE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHADOSE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHENAMINE HIPPURATE 1G TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHERGINE 0.2MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
METHIMAZOLE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHIMAZOLE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHOCARBAMOL 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
METHOTREXATE 1GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHOTREXATE 25MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLIN 10MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | P |
METHYLIN 10MG TABLET CHEWABLE |
2 |
Tier 2 |
25% | 25% | P |
METHYLIN 10MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
25% | 25% | P |
METHYLIN 2.5MG TABLET CHEWABLE |
2 |
Tier 2 |
25% | 25% | P |
METHYLIN 20MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLIN 5MG TABLET CHEWABLE |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLIN 5MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
25% | 25% | P |
METHYLIN ER 10MG TABLET SA |
1 |
Tier 1 |
25% | 25% | P |
METHYLIN ER 20MG TABLET SA |
1 |
Tier 1 |
25% | 25% | P |
METHYLIN TABLET 5MG (100 CT) |
1 |
Tier 1 |
25% | 25% | P |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLPHENIDATE 20MG TABLET SA |
1 |
Tier 1 |
25% | 25% | P |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | P |
METHYLPHENIDATE ER 20MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLPR ACE INJ 80MG/ML |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 1GM VIAL |
2 |
Tier 2 |
25% | 25% | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE 40MG/ML VL 5ML |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE 8MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 500 MG/4ML |
2 |
Tier 2 |
25% | 25% | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
25% | 25% | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE 5MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE TABLET USP 10MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCCINATE 100MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCCINATE 200MG TABLET ER (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METROGEL TOPICAL 1% GEL |
2 |
Tier 2 |
25% | 25% | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE 250MG TABLET (250 CT) |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE 375MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 500MG/100ML |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
MEXILETINE 150MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MEXILETINE 200MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MEXILETINE 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MIACALCIN 200IU/ML VIAL |
2 |
Tier 2 |
25% | 25% | None |
MIACALCIN 200UNITS NASAL SPRA |
2 |
Tier 2 |
25% | 25% | Q:12 /90Days |
MICONAZOLE 3 200MG SUPPOS. |
1 |
Tier 1 |
25% | 25% | None |
MICROGESTIN 1-0.02MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Tier 1 |
25% | 25% | None |
MICROGESTIN FE 1/20 TABLET |
1 |
Tier 1 |
25% | 25% | None |
MIDODRINE HCL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
1 |
Tier 1 |
25% | 25% | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
25% | 25% | Q:8 /30Days |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HCL 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HCL 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MINTEZOL 500MG TABLET CHEW |
2 |
Tier 2 |
25% | 25% | None |
MINTEZOL 500MG/5ML SUSP |
2 |
Tier 2 |
25% | 25% | None |
MIRAPEX 0.125MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MIRAPEX 0.25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MIRAPEX 0.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MIRAPEX 0.75MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MIRAPEX 1.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRAPEX 1MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MIRTAZAPINE 15MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MIRTAZAPINE 45MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MIRTAZAPINE TABLET 45MG |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MIRTAZAPINE TABLET 7.5MG (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /90Days |
MISOPROSTOL 100MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MISOPROSTOL 200MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MITOMYCIN 40MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
MITOMYCIN POWDER FOR INJECTION USP 5MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
MOBAN 10MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MOBAN 25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MOBAN 50MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MOBAN 5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MOEXIPRIL HCL 15MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Tier 1 |
25% | 25% | None |
MONONESSA 0.25-0.035 TABLET |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE 15MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE 30MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE 5MG 25 X 1ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE INJECTION 1 MG/ML |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE TABLET ER 15MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE TABLET ER 200MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
2 |
Tier 2 |
25% | 25% | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
MUSTARGEN 10MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
MYCOBUTIN 150MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYDRAL 0.5% DROPS |
1 |
Tier 1 |
25% | 25% | None |
MYDRAL 1% DROPS |
1 |
Tier 1 |
25% | 25% | None |
MYFORTIC 180MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
MYFORTIC 360MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
MYLOTARG 5MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
MYRAC 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MYRAC 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MYRAC 75MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MYTELASE 10MG CAPLET |
2 |
Tier 2 |
25% | 25% | None |