2010 Medicare Part D Plan Formulary Information |
Advocare Vitality Rx (HMO-POS) (H5211-005-0)
Benefit Details
|
The Advocare Vitality Rx (HMO-POS) (H5211-005-0) Formulary Drugs Starting with the Letter M in Junea County, WI: CMS MA Region 14 which includes: WI
|
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 |
$30.00 | $90.00 | None |
MACROBID 100MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MACRODANTIN 100MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MACRODANTIN 25MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MACRODANTIN 50MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MALARONE 250-100MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MALARONE 62.5-25MG PED TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAPROTILINE 25MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARGESIC H 5MG-500MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MARINOL 10MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P |
MARINOL 2.5MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P |
MARINOL 5MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P |
MARPLAN 10MG TABLET (100 CT) |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MATULANE 50MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MAVIK 1MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAVIK 2MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAVIK 4MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAXALT 10MG TABLET 12 CRTN |
2 |
Tier 2 |
$30.00 | $90.00 | Q:18 /30Days |
MAXALT 5MG TABLET 12 CRTN |
2 |
Tier 2 |
$30.00 | $90.00 | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
2 |
Tier 2 |
$30.00 | $90.00 | Q:18 /30Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
2 |
Tier 2 |
$30.00 | $90.00 | Q:18 /30Days |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAXIDONE 10/750MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAXIPIME 1G VIAL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MAXIPIME 2G ADD-VANTAGE VL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MAXITROL EYE OINTMENT |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAXITROL SUS 0.1% OP |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAXZIDE 50/75 TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MAXZIDE-25MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MECLOFENAMATE 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEDROL 16MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEDROL 2MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEDROL 32MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEDROL 4MG DOSEPAK |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEDROL 4MG DOSEPAK (100 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEDROL 8MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEFOXIN 10GM VIAL |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEFOXIN 1GM VIAL |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEFOXIN 1GM/50ML PIGGYBACK |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEFOXIN 2GM VIAL |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEFOXIN 2GM/50ML PIGGYBACK |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEGACE 40MG/ML ORAL SUSP |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MELOXICAM 15MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MELOXICAM TABLETS 7.5MG |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MENEST 0.3MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MENEST 0.625MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MENEST 1.25MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MENEST 2.5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MENOSTAR 14 MCG/DAY PATCH |
2 |
Tier 2 |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEPERIDINE 50MG/5ML SYRUP |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPERIDINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPERIDINE HCL INJECTION 75MG 25 X 1ML VIALSD |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPERIDINE HCL TABLET 100MG (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPROBAMATE 200MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPROBAMATE 400MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPRON 750MG/5ML ORAL SUSP |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MERUVAX II VACCINE/DILUENT |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MESALAMINE 4G/60ML ENEMA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESNEX 400MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MESTINON 180MG TIMESPAN |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MESTINON 60MG/5ML SYRUP |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MESTINON TABLETS 60MG 100 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | None |
METADATE CD 10MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METADATE CD 20MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METADATE CD 30MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METADATE CD 40MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METADATE CD 50MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METADATE CD 60MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METADATE ER 20MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 10MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METAPROTERENOL 10MG/5ML SYR |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METFORMIN HCL 850MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METFORMIN HCL ER 750MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHADONE 10MG/5ML SOLUTION |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METHADONE 5MG/5ML SOLUTION |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METHADONE HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHADOSE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHADOSE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHENAMINE HIPPURATE 1G TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHIMAZOLE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHIMAZOLE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHITEST 10MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METHOCARBAMOL 500MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHOTREXATE 25MG/ML VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLDOPA 250MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLDOPA 500MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLDOPATE 250MG/5ML VIAL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLIN 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLIN 10MG TABLET CHEWABLE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METHYLIN 2.5MG TABLET CHEWABLE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
METHYLIN 20MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLIN ER 10MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLIN ER 20MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLIN SOLUTION 5MG/5ML 500 ML BOT |
3 |
Tier 3 |
$60.00 | $180.00 | None |
METHYLIN TABLET 5MG (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE 1GM VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE 8MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Tier 1 |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METROCREAM 0.75% CREAM |
3 |
Tier 3 |
$60.00 | $180.00 | None |
METROLOTION TOPICAL 0.75% |
3 |
Tier 3 |
$60.00 | $180.00 | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE 375MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE 500MG/100ML |
3 |
Tier 3 |
$60.00 | $180.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE VAGINAL GEL 0.75% |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEVACOR 10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEVACOR 20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEVACOR 40MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MEXILETINE 150MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEXILETINE 200MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEXILETINE 250MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIACALCIN 200IU/ML VIAL |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MIACALCIN 200UNITS NASAL SPRA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICARDIS 20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MICARDIS 40MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MICARDIS 80MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MICARDIS HCT 40/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MICARDIS HCT 80/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MICARDIS HCT 80/25MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MICONAZOLE 3 200MG SUPPOS. |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MICROGESTIN 1-0.02MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MICROGESTIN FE 1/20 TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROZIDE 12.5MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MIDODRINE HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MINIPRESS 1MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MINIPRESS 2MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MINIPRESS 5MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MINITRAN 0.1MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINITRAN 0.2MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINITRAN 0.4MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINITRAN 0.6MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCIN PELLET FILLED CAPSULES 100MG (50 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MINOCIN PELLET FILLED CAPSULES 50MG (100 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCYCLINE HCL 100MG TABLET 60 EA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCYCLINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRAPEX 0.125MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MIRAPEX 0.25MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MIRAPEX 0.5MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MIRAPEX 0.75MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MIRAPEX 1.5MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MIRAPEX 1MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MIRTAZAPINE 15MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRTAZAPINE TABLET 7.5MG (30 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRTAZAPINE TABLETS 45MG 30 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MISOPROSTOL 100MCG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MISOPROSTOL 200MCG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOBAN 10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MOBAN 25MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MOBAN 50MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MOBAN 5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MOBIC 15MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOBIC 7.5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MOBIC 7.5MG/5ML SUSPENSION |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MODICON TABLET 0.5/35 |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MOEXIPRIL HCL 15MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONODOX 100MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONODOX 50MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONODOX 75MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONOKET 10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONOKET 20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MONOPRIL 10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONOPRIL 20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONOPRIL 40MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONOPRIL HCT 10/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MONOPRIL HCT 20/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONUROL PAK GRANULES 3 GM |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE 15MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE 30MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MS CONTIN 100MG TABLET SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MS CONTIN 15MG TABLET 100 EA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MS CONTIN 200MG TABLET SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MS CONTIN 30MG TABLET SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MS CONTIN 60MG TABLET SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MUSTARGEN 10MG VIAL |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MYAMBUTOL 100MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MYAMBUTOL 400MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MYCOBUTIN 150MG CAPSULE |
2 |
Tier 2 |
$30.00 | $90.00 | None |
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYCOSTATIN 100000UNITS/GM PW |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MYDRAL 0.5% DROPS |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYDRAL 1% DROPS |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYDRIACYL 1% EYE DROPS |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MYFORTIC 180MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | P |
MYFORTIC 360MG TABLET |
2 |
Tier 2 |
$30.00 | $90.00 | P |
MYRAC 100MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYRAC 50MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYRAC 75MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYSOLINE 50MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | None |
MYTELASE 10MG CAPLET |
2 |
Tier 2 |
$30.00 | $90.00 | None |