2011 Medicare Part D Plan Formulary Information |
First Health Part D Premier Plus (PDP) (S5670-036-0)
Benefit Details
|
The First Health Part D Premier Plus (PDP) (S5670-036-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 6 which includes: PA WV
|
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 |
3 |
Preferred Brand |
30% | 27% | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MALATHION 5 MG/ML TOPICAL LOTION |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MAPROTILINE 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MAPROTILINE 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MAPROTILINE 75MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MARGESIC H 5MG-500MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MATULANE 50MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
MAXALT 10MG TABLET 12 CRTN |
3 |
Preferred Brand |
30% | 27% | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT 5MG TABLET 12 CRTN |
3 |
Preferred Brand |
30% | 27% | Q:12 /30Days |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
3 |
Preferred Brand |
30% | 27% | Q:12 /30Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
3 |
Preferred Brand |
30% | 27% | Q:12 /30Days |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
3 |
Preferred Brand |
30% | 27% | None |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
2 |
Generic |
$25.00 | $62.50 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
2 |
Generic |
$25.00 | $62.50 | None |
MECLOFENAMATE 100MG CAPSULE |
2 |
Generic |
$25.00 | $62.50 | None |
MECLOFENAMATE 50MG CAPSULE |
2 |
Generic |
$25.00 | $62.50 | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:1 /90Days |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Generic |
$25.00 | $62.50 | None |
MEGACE ES 625MG/5ML SUSP |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:150 /30Days |
MEGESTROL 20MG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
2 |
Generic |
$25.00 | $62.50 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Generic |
$25.00 | $62.50 | None |
MELOXICAM 15MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MELOXICAM TABLETS 7.5MG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
MENEST 2.5MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Preferred Brand |
30% | 27% | None |
MENOSTAR 14 MCG/DAY PATCH |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:4 /28Days |
MENTAX 1% CREAM 15G TUBE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MENVEO INJECTION KIT |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE 10MG/ML SYRINGE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE 25MG/ML VIAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE 50MG/5ML SYRUP |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEPERIDINE 50MG/ML VIAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE HCL 50MG TABLET (100 CT) |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE HCL INJECTION 75MG 25 X 1ML VIALSD |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE HCL TABLET 100MG (100 CT) |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPERIDINE HYDROCHLORIDE INJECTION 100MG/ML 25 X 1 ML VIALSD |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPROBAMATE 200MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPROBAMATE 400MG TABLET (100 CT) |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MEPRON 750MG/5ML ORAL SUSP |
5 |
Specialty Tier |
33% | N/A | P |
MERCAPTOPURINE 50MG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
MEROPENEM FOR INJECTION |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MERUVAX II VACCINE/DILUENT |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MESALAMINE 4G/60ML ENEMA |
2 |
Generic |
$25.00 | $62.50 | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MESTINON 180MG TIMESPAN |
3 |
Preferred Brand |
30% | 27% | None |
MESTINON 60MG/5ML SYRUP |
3 |
Preferred Brand |
30% | 27% | None |
METADATE CD 10MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:30 /30Days |
METADATE CD 20MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:30 /30Days |
METADATE CD 30MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:30 /30Days |
METADATE CD 40MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:30 /30Days |
METADATE CD 50MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METADATE CD 60MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:30 /30Days |
METADATE ER 20MG TABLET SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METAPROTERENOL 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METAPROTERENOL 10MG/5ML SYR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METAPROTERENOL 20MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METAXALONE 800 MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:120 /30Days |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL 850MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL ER 750MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE 10MG/5ML SOLUTION |
3 |
Preferred Brand |
30% | 27% | None |
METHADONE 5MG/5ML SOLUTION |
3 |
Preferred Brand |
30% | 27% | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
3 |
Preferred Brand |
30% | 27% | None |
METHADONE HYDROCHLORIDE TABLETS 10 MG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHADOSE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHADOSE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHENAMINE HIPPURATE 1G TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHERGINE 0.2MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
METHIMAZOLE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHIMAZOLE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHOCARBAMOL 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHOTREXATE INJECTION 25 MG/ML |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLDOPA 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLIN 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLIN 20MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLIN ER 10MG TABLET SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLIN ER 20MG TABLET SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLIN TABLET 5MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPHENIDATE 20MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | 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 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPR ACE INJ 80MG/ML |
2 |
Generic |
$25.00 | $62.50 | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 1GM VIAL |
2 |
Generic |
$25.00 | $62.50 | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 4 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 40MG/ML VL 5ML |
2 |
Generic |
$25.00 | $62.50 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL |
2 |
Generic |
$25.00 | $62.50 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
2 |
Generic |
$25.00 | $62.50 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE INJECTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOLAZONE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOLAZONE 2.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOLAZONE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METROGEL TOPICAL 1% GEL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 375MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE INJECTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE VAGINAL GEL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEXILETINE 150MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEXILETINE 200MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEXILETINE 250MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MICARDIS 20MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
MICARDIS 40MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICARDIS 80MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
MICARDIS HCT 40/12.5MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
MICARDIS HCT 80/12.5MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
MICARDIS HCT 80/25MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
MICROGESTIN 1-0.02MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MICROGESTIN FE 1/20 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MIDODRINE HCL 10MG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Generic |
$25.00 | $62.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
2 |
Generic |
$25.00 | $62.50 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:8 /28Days |
MILLIPRED TABLETS 5MG |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MINOXIDIL 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MINOXIDIL 2.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE 15MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE TABLET 7.5MG (30 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE TABLETS 45MG 30 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MISOPROSTOL 100MCG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
MISOPROSTOL 200MCG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL HCL 15MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | 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 |
Preferred Generic |
$0.00 | $0.00 | None |
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MONUROL PAK GRANULES 3 GM |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE 20 MG/ML SOL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Generic |
$25.00 | $62.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 5MG 25 X 1ML VIAL |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Generic |
$25.00 | $62.50 | None |
MORPHINE SULFATE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOTOFEN TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MOXATAG 775 MG ER TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:10 /10Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:60 /30Days |
MUPIROCIN 2% OINTMENT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MYCOBUTIN 150MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
MYDRAL 0.5% DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MYDRAL 1% DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MYTELASE 10MG CAPLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |