2011 Medicare Part D Plan Formulary Information |
Clarian Medicare Select Plus (HMO) (H7220-003-0)
Benefit Details
|
The Clarian Medicare Select Plus (HMO) (H7220-003-0) Formulary Drugs Starting with the Letter M in Monroe County, IN: CMS MA Region 13 which includes: IN
|
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 |
$35.00 | $87.50 | None |
MACROBID 100MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MACRODANTIN 100MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MACRODANTIN 50MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAGNACET 2.5-400MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MAGNACET TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MAGNACET TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MAGNACET TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MAPROTILINE 25MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MAPROTILINE 50MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAPROTILINE 75MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MARGESIC H 5MG-500MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MATULANE 50MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MAVIK 1MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAVIK 2MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAVIK 4MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAXALT 10MG TABLET 12 CRTN |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:12 /30Days |
MAXALT 5MG TABLET 12 CRTN |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:12 /30Days |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:12 /30Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXIDONE 10/750MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAXITROL EYE OINTMENT |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAXITROL SUS 0.1% OP |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MAXZIDE 37.5 MG-25 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MECLOFENAMATE 100MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEDROL 16MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEDROL 32MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROL 4MG DOSEPAK |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEDROL 4MG DOSEPAK (100 CT) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEDROL 8MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEGACE 40MG/ML ORAL SUSP |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEGACE ES 625MG/5ML SUSP |
2 |
Tier 2 |
$35.00 | $87.50 | None |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MELOXICAM 15MG TABLET (500 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MELOXICAM TABLETS 7.5MG |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
4 |
Tier 4 |
30% | N/A | P |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
2 |
Tier 2 |
$35.00 | $87.50 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Tier 2 |
$35.00 | $87.50 | None |
MENOSTAR 14 MCG/DAY PATCH |
2 |
Tier 2 |
$35.00 | $87.50 | None |
MENTAX 1% CREAM 15G TUBE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MENVEO INJECTION KIT |
2 |
Tier 2 |
$35.00 | $87.50 | 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 |
$5.50 | $13.75 | None |
MEPERIDINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEPERIDINE HCL TABLET 100MG (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEPROBAMATE 200MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEPROBAMATE 400MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEPRON 750MG/5ML ORAL SUSP |
2 |
Tier 2 |
$35.00 | $87.50 | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEROPENEM FOR INJECTION |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MERUVAX II VACCINE/DILUENT |
2 |
Tier 2 |
$35.00 | $87.50 | None |
MESALAMINE 4G/60ML ENEMA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MESNEX 400MG TABLET |
4 |
Tier 4 |
30% | N/A | P |
MESNEX INJECTION |
4 |
Tier 4 |
30% | N/A | P |
MESTINON TABLETS 60MG 100 BOT |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METAGLIP 2.5/250MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METAGLIP 2.5/500MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METAGLIP 5/500MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METAPROTERENOL 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METAPROTERENOL 10MG/5ML SYR |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METAPROTERENOL 20MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METAXALONE 800 MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METFORMIN HCL 850MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METFORMIN HCL ER 750MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADONE 10MG/5ML SOLUTION |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADONE 5MG/5ML SOLUTION |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADONE HYDROCHLORIDE TABLETS 10 MG |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADOSE 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHADOSE 5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHENAMINE HIPPURATE 1G TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHIMAZOLE TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHIMAZOLE TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHOCARBAMOL 500MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOTREXATE INJECTION 25 MG/ML |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLDOPA 250MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLDOPA 500MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLDOPATE 250MG/5ML VIAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLIN 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLIN 20MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLIN ER 10MG TABLET SA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLIN ER 20MG TABLET SA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLIN TABLET 5MG (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPREDNISOLONE 1GM VIAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOCLOPRAMIDE 10 MG ORAL TABLET [REGLAN] |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOCLOPRAMIDE INJECTION |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOCLOPRAMIDE TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METROCREAM 0.75% CREAM |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METROGEL TOPICAL 1% GEL |
3 |
Tier 3 |
$85.00 | $212.50 | None |
METROLOTION TOPICAL 0.75% |
3 |
Tier 3 |
$85.00 | $212.50 | P |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE 375MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE INJECTION |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
METRONIDAZOLE VAGINAL GEL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEVACOR 20MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEVACOR 40MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MEXILETINE 150MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEXILETINE 200MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MEXILETINE 250MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIACALCIN 200UNITS NASAL SPRA |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MICROGESTIN 1-0.02MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MICROGESTIN FE 1/20 TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MICROZIDE 12.5MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:8 /30Days |
MINIPRESS 1MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MINIPRESS 2MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MINIPRESS 5MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MINITRAN 0.1MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINITRAN 0.2MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINITRAN 0.4MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINITRAN 0.6MG/HR PATCH 30 EA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCIN PELLET FILLED CAPSULES 50MG (100 CT) |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOCYCLINE HCL 100MG TABLET 60 EA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOCYCLINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIRAPEX 0.125MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MIRAPEX 0.25MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRAPEX 0.5MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MIRAPEX 0.75MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MIRAPEX 1.5MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MIRAPEX 1MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MIRAPEX ER 0.375 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MIRAPEX ER 0.75 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MIRAPEX ER 1.5 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MIRAPEX ER 3 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MIRAPEX ER 4.5 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MIRTAZAPINE 15MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIRTAZAPINE TABLET 7.5MG (30 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MIRTAZAPINE TABLETS 45MG 30 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MISOPROSTOL 100MCG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MISOPROSTOL 200MCG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
4 |
Tier 4 |
30% | N/A | P |
MOBIC 15MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MOBIC 7.5MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MODICON TABLET 0.5/35 |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MOEXIPRIL HCL 15MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MONODOX 100MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MONODOX 50MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONOKET 10MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MONOPRIL 10MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MONOPRIL 40MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MORPHINE SULFATE TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MORPHINE SULFATE TABLETS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOZOBIL SOLUTION 24MG/1.2ML |
4 |
Tier 4 |
30% | N/A | P |
MS CONTIN 100MG TABLET SA |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MS CONTIN 15MG TABLET 100 EA |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MS CONTIN 200MG TABLET SA |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MS CONTIN 30MG TABLET SA |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MS CONTIN 60MG TABLET SA |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MUSTARGEN 10MG VIAL |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MYAMBUTOL 100MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MYCAMINE 50MG VIAL |
4 |
Tier 4 |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCAMINE FOR INJECTION SOLUTION |
4 |
Tier 4 |
30% | N/A | P |
MYCOBUTIN 150MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
$5.50 | $13.75 | P |
MYDRAL 0.5% DROPS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MYDRAL 1% DROPS |
1 |
Tier 1 |
$5.50 | $13.75 | None |
MYDRIACYL 1% EYE DROPS |
3 |
Tier 3 |
$85.00 | $212.50 | P |
MYFORTIC 180MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | P |
MYFORTIC 360MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | P |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
3 |
Tier 3 |
$85.00 | $212.50 | None |