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AARP MedicareRx Enhanced (PDP) (S5820-143-0)
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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2010 Medicare Part D Plan Formulary Information
AARP MedicareRx Enhanced (PDP) (S5820-143-0)
Benefit Details  
The AARP MedicareRx Enhanced (PDP) (S5820-143-0)
Formulary Drugs Starting with the Letter M
in CMS PDP Region 36 which includes: GU
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 Generic Preferred Brand $42.00$111.00None
MACROBID 100MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MACRODANTIN 100MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MACRODANTIN 25MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MACRODANTIN 50MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MAGNACET 10MG-400MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAGNACET 2.5-400MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAGNACET 5MG-400MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAGNACET 7.5-400MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MAGNESIUM SULFATE 4% IV SOLUTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MAGNESIUM SULFATE 8% IV SOLUTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MALARONE 250-100MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MALARONE 62.5-25MG PED TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAPROTILINE 25MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MAPROTILINE 50MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MAPROTILINE 75MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MARGESIC H 5MG-500MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MARINOL 10MG CAPSULE   4 Tier 4 Specialty 33%33%P
MARINOL 2.5MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MARINOL 5MG CAPSULE   4 Tier 4 Specialty 33%33%P
MARPLAN 10MG TABLET (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MATULANE 50MG CAPSULE   4 Tier 4 Specialty 33%33%None
MAVIK 1MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAVIK 2MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAVIK 4MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXALT 10MG TABLET 12 CRTN   2 Tier 2 Generic Preferred Brand $42.00$111.00Q:12
/30Days
MAXALT 5MG TABLET 12 CRTN   2 Tier 2 Generic Preferred Brand $42.00$111.00Q:12
/30Days
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE   2 Tier 2 Generic Preferred Brand $42.00$111.00Q:12
/30Days
MAXALT MLT 5MG TABLET 4X3 UNIT CASE   2 Tier 2 Generic Preferred Brand $42.00$111.00Q:12
/30Days
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MAXIDONE 10/750MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXIPIME 1G VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXIPIME 2G ADD-VANTAGE VL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXITROL EYE OINTMENT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXITROL SUS 0.1% OP   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXZIDE 50/75 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MAXZIDE-25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEBENDAZOLE 100MG TABLET CHEW   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MECLOFENAMATE 100MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MECLOFENAMATE 50MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEDROL 16MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEDROL 2MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEDROL 32MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEDROL 4MG DOSEPAK   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEDROL 4MG DOSEPAK (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEDROL 8MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEDROXYPROGESTERONE 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEDROXYPROGESTERONE 2.5MG   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEDROXYPROGESTERONE 5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MEFLOQUINE HCL 250MG TABLET 25 BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEFOXIN 10GM VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEFOXIN 1GM VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEFOXIN 1GM/50ML PIGGYBACK   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEFOXIN 2GM VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEFOXIN 2GM/50ML PIGGYBACK   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEGACE 40MG/ML ORAL SUSP   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEGACE ES 625MG/5ML SUSP   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEGESTROL 20MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEGESTROL ACETATE 40MG TABLET (250 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MELOXICAM 15MG TABLET (500 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MELOXICAM 7.5MG/5ML SUSPENSION ORAL   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MELOXICAM TABLETS 7.5MG   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MENEST 0.3MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MENEST 0.625MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MENEST 1.25MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MENEST 2.5MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MENOMUNE-A/C/Y/W-135 VIAL   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MENOSTAR 14 MCG/DAY PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MENTAX 1% CREAM 15G TUBE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MEPERIDINE 10MG/ML SYRINGE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEPERIDINE 25MG/ML VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEPERIDINE 50MG/5ML SYRUP   1 Tier 1 Preferred Generic Brand $7.00$4.00S
MEPERIDINE 50MG/ML VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEPERIDINE HCL 50MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00S
MEPERIDINE HCL INJECTION 75MG 25 X 1ML VIALSD   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEPERIDINE HCL TABLET 100MG (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00S
MEPERIDINE HYDROCHLORIDE INJECTION 100MG/ML 25 X 1 ML VIALSD   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEPROBAMATE 200MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00P
MEPROBAMATE 400MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00P
MEPRON 750MG/5ML ORAL SUSP   4 Tier 4 Specialty 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MERCAPTOPURINE 50MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MERREM INJECTION 500MG 10X20MLVIALS VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MERUVAX II VACCINE/DILUENT   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MESALAMINE 4G/60ML ENEMA   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MESNEX 100MG/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MESNEX 400MG TABLET   4 Tier 4 Specialty 33%33%None
MESTINON 180MG TIMESPAN   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MESTINON 60MG/5ML SYRUP   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MESTINON TABLETS 60MG 100 BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METADATE CD 10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METADATE CD 20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:93
/31Days
METADATE CD 30MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
METADATE CD 40MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
METADATE CD 50MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
METADATE CD 60MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
METADATE ER 20MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:93
/31Days
METAGLIP 2.5/250MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METAGLIP 2.5/500MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METAGLIP 5/500MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METAPROTERENOL 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METAPROTERENOL 10MG/5ML SYR   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METAPROTERENOL 20MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METFORMIN HCL 1000MG TABLET (500 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METFORMIN HCL 500MG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METFORMIN HCL 850MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METFORMIN HCL ER 500MG TABLET SR 24HR   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METFORMIN HCL ER 750MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHADONE 10MG/5ML SOLUTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHADONE 5MG/5ML SOLUTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHADONE HCL 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHADONE HCL 5MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHADONE INJ 10MG/ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METHADOSE 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHADOSE 5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHAZOLAMIDE 25MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHAZOLAMIDE 50MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHENAMINE HIPPURATE 1G TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHERGINE 0.2MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
METHIMAZOLE 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHIMAZOLE 5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHITEST 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METHOCARBAMOL 500MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
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 Preferred Generic Brand $7.00$4.00None
METHOTREXATE 1GM VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHOTREXATE 2.5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHOTREXATE 25MG/ML VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT   2 Tier 2 Generic Preferred Brand $42.00$111.00None
METHYCLOTHIAZIDE 5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLDOPA 250MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLDOPA 500MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLDOPA/HCTZ 250-15 TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLDOPA/HCTZ 250-25 TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHYLDOPATE 250MG/5ML VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLIN 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:186
/31Days
METHYLIN 10MG TABLET CHEWABLE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:186
/31Days
METHYLIN 10MG/5ML SOLUTION ORAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:930
/31Days
METHYLIN 2.5MG TABLET CHEWABLE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:744
/31Days
METHYLIN 20MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:93
/31Days
METHYLIN 5MG TABLET CHEWABLE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:372
/31Days
METHYLIN ER 10MG TABLET SA   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:186
/31Days
METHYLIN ER 20MG TABLET SA   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:93
/31Days
METHYLIN SOLUTION 5MG/5ML 500 ML BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:1860
/31Days
METHYLIN TABLET 5MG (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:372
/31Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHYLPHENIDATE 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:186
/31Days
METHYLPHENIDATE 20MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:93
/31Days
METHYLPHENIDATE 5MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:372
/31Days
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:93
/31Days
METHYLPR ACE INJ 80MG/ML   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE 16MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE 1GM VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE 32MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE 40MG/ML VL 5ML   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE 8MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METHYLPREDNISOLONE TABLETS 4MG 21 PKT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METIPRANOLOL 0.3% EYE DROPS   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOCLOPRAMIDE 5MG/ML VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOLAZONE 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOLAZONE 2.5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOLAZONE 5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METOPROLOL SUCCINATE 25MG TABLET SR 24HR   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL SUCCINATE 50MG TABLET SR 24HR   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METROCREAM 0.75% CREAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METROGEL TOPICAL 1% GEL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METROLOTION TOPICAL 0.75%   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
METRONIDAZOLE 0.75% CREAM   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE 0.75% LOTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE 375MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE 500MG/100ML   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METRONIDAZOLE VAGINAL GEL 0.75%   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEVACOR 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEVACOR 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEVACOR 40MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MEXILETINE 150MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEXILETINE 200MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MEXILETINE 250MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MIACALCIN 200IU/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00P
MIACALCIN 200UNITS NASAL SPRA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:4
/31Days
MICARDIS 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
MICARDIS 40MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MICARDIS 80MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
MICARDIS HCT 40/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
MICARDIS HCT 80/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
MICARDIS HCT 80/25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
MICONAZOLE 3 200MG SUPPOS.   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MICROGESTIN 1-0.02MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MICROGESTIN 1.5-0.03MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MICROGESTIN FE 1.5/30 TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MICROGESTIN FE 1/20 TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MICROZIDE 12.5MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MIDODRINE HCL 10MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MIDODRINE HCL 2.5MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIDODRINE HCL 5MG TABLET (100 CT)   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIGERGOT 2-100MG SUPPOSITORY RECTAL   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:8
/31Days
MILLIPRED 10;5MG;ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MILLIPRED TABLETS 5MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MINIPRESS 1MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MINIPRESS 2MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MINIPRESS 5MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MINITRAN 0.1MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MINITRAN 0.2MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic Brand $7.00$4.00None
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 Preferred Generic Brand $7.00$4.00None
MINITRAN 0.6MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MINOCIN PELLET FILLED CAPSULES 100MG (50 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MINOCIN PELLET FILLED CAPSULES 50MG (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MINOCYCLINE 100MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MINOCYCLINE 50MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MINOCYCLINE HCL 100MG TABLET 60 EA   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MINOCYCLINE HCL 75MG CAPSULE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MINOCYCLINE HCL 75MG TABLET (100 CT)   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MINOXIDIL 10MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MINOXIDIL 2.5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MIRAPEX 0.125MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIRAPEX 0.25MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIRAPEX 0.5MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIRAPEX 0.75MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIRAPEX 1.5MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIRAPEX 1MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MIRTAZAPINE 15MG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX   1 Tier 1 Preferred Generic Brand $7.00$4.00None
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 Preferred Generic Brand $7.00$4.00None
MIRTAZAPINE TABLET 7.5MG (30 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MIRTAZAPINE TABLETS 45MG 30 BOT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MISOPROSTOL 100MCG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MISOPROSTOL 200MCG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MITOXANTRONE INJECTION 2MG 125ML VIAL   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MOBAN 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOBAN 25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOBAN 50MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOBAN 5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MOBIC 15MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOBIC 7.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOBIC 7.5MG/5ML SUSPENSION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MODICON TABLET 0.5/35   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOEXIPRIL HCL 15MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MOEXIPRIL HCL 7.5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MONODOX 100MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONODOX 50MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONODOX 75MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONOKET 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONOKET 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MONOPRIL 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONOPRIL 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONOPRIL 40MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONOPRIL HCT 10/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MONOPRIL HCT 20/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MONUROL PAK GRANULES 3 GM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MORPHINE SULFATE 100MG TABLET SA   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:6
/1Days
MORPHINE SULFATE 15MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MORPHINE SULFATE 15MG TABLET SA   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:4
/1Days
MORPHINE SULFATE 200MG TABLET SA   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:6
/1Days
MORPHINE SULFATE 30MG TABLET   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MORPHINE SULFATE 30MG TABLET SA   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:4
/1Days
MORPHINE SULFATE 5MG 25 X 1ML VIAL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL   1 Tier 1 Preferred Generic Brand $7.00$4.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MORPHINE SULFATE ORAL SOLUTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MORPHINE SULFATE ORAL SOLUTION   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MORPHINE SULFATE TABLET ER 60MG (100 CT)   1 Tier 1 Preferred Generic Brand $7.00$4.00Q:4
/1Days
MOTOFEN TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOVIPREP 7.5-2.691G POWDER IN PACKET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MOXATAG 775 MG ER TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00S
MS CONTIN 100MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:6
/1Days
MS CONTIN 15MG TABLET 100 EA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:4
/1Days
MS CONTIN 200MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:6
/1Days
MS CONTIN 30MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:4
/1Days
MS CONTIN 60MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:4
/1Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00P
MUPIROCIN 2% OINTMENT   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MUSTARGEN 10MG VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYAMBUTOL 100MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYAMBUTOL 400MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYCAMINE 50MG VIAL   4 Tier 4 Specialty 33%33%None
MYCAMINE FOR INJECTION SOLUTION   4 Tier 4 Specialty 33%33%None
MYCOBUTIN 150MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT   2 Tier 2 Generic Preferred Brand $42.00$111.00P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT   2 Tier 2 Generic Preferred Brand $42.00$111.00P
MYCOSTATIN 100000UNITS/GM PW   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MYDRAL 0.5% DROPS   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MYDRAL 1% DROPS   1 Tier 1 Preferred Generic Brand $7.00$4.00None
MYDRIACYL 1% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYFORTIC 180MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00P
MYFORTIC 360MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00P
MYLOTARG 5MG VIAL   4 Tier 4 Specialty 33%33%None
MYOBLOC 5000UNITS/1ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYOZYME 50MG VIAL   4 Tier 4 Specialty 33%33%None
MYRAC 100MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MYRAC 50MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
MYRAC 75MG TABLET   2 Tier 2 Generic Preferred Brand $42.00$111.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MYSOLINE 50MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
MYTELASE 10MG CAPLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D AARP MedicareRx Enhanced (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug 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).

  • 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 $310 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 $2830) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 October 2010 )

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 Part D plan provider.