2011 Medicare Part D Plan Formulary Information |
Triple-S Medicare Optimo Plus (PPO) (H4005-004-0)
Benefit Details
|
The Triple-S Medicare Optimo Plus (PPO) (H4005-004-0) Formulary Drugs Starting with the Letter M in Guayanilla County, PR: CMS MA Region 0 which includes: PR
|
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 |
Tier 3 |
$45.00 | $135.00 | None |
MACROBID 100MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MACRODANTIN 100MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MACRODANTIN 50MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MALARONE 250-100MG TABLET |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MALARONE 62.5-25MG PED TABLET |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MAPROTILINE 25MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MAPROTILINE 50MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MAPROTILINE 75MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MARINOL 10MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARINOL 2.5MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MARINOL 5MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MATULANE 50MG CAPSULE |
5 |
Tier 5 |
25% | 25% | None |
MAVIK 1MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MAVIK 2MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MAVIK 4MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MAXIPIME 1G VIAL |
4 |
Tier 4 |
25% | 25% | P |
MAXITROL EYE OINTMENT |
4 |
Tier 4 |
25% | 25% | None |
MAXITROL SUS 0.1% OP |
4 |
Tier 4 |
25% | 25% | None |
MAXZIDE 37.5 MG-25 MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEBENDAZOLE 100MG TABLET CHEW |
3 |
Tier 3 |
$45.00 | $135.00 | None |
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 |
MEDROL 16MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MEDROL 32MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MEDROL 4MG DOSEPAK |
4 |
Tier 4 |
25% | 25% | None |
MEDROL 4MG DOSEPAK (100 CT) |
4 |
Tier 4 |
25% | 25% | None |
MEDROL 8MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEDROXYPROGESTERONE 5MG 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 ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
$5.00 | $15.00 | Q:1 /90Days |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEGACE 40MG/ML ORAL SUSP |
4 |
Tier 4 |
25% | 25% | 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 |
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 TABLETS 7.5MG |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MENEST 0.3MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MENEST 0.625MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 1.25MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MENEST 2.5MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MEPERIDINE 50MG/ML VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MEPERIDINE HYDROCHLORIDE INJECTION 100MG/ML 25 X 1 ML VIALSD |
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 |
5 |
Tier 5 |
25% | 25% | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MERUVAX II VACCINE/DILUENT |
3 |
Tier 3 |
$45.00 | $135.00 | 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 |
5 |
Tier 5 |
25% | 25% | P |
MESTINON 180MG TIMESPAN |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MESTINON 60MG/5ML SYRUP |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MESTINON TABLETS 60MG 100 BOT |
4 |
Tier 4 |
25% | 25% | None |
METAGLIP 2.5/250MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
METAGLIP 2.5/500MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
METAGLIP 5/500MG TABLET |
4 |
Tier 4 |
25% | 25% | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL ER 750MG TABLET (100 CT) |
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 TABLETS |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHIMAZOLE TABLETS |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHOCARBAMOL 500MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHOTREXATE INJECTION 25 MG/ML |
1 |
Tier 1 |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROMIDE 2.5MG 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 |
METHYLIN ER 10MG TABLET SA |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPR ACE INJ 80MG/ML |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE 32MG 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 |
METHYLPREDNISOLONE 4 MG ORAL TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METHYLPREDNISOLONE 40MG/ML VL 5ML |
1 |
Tier 1 |
$5.00 | $15.00 | P |
METHYLPREDNISOLONE 8 MG ORAL 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 | P |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
1 |
Tier 1 |
$5.00 | $15.00 | P |
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 10 MG ORAL TABLET [REGLAN] |
4 |
Tier 4 |
25% | 25% | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOCLOPRAMIDE INJECTION |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT 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 |
METOCLOPRAMIDE TABLETS |
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 |
METROCREAM 0.75% CREAM |
4 |
Tier 4 |
25% | 25% | None |
METROLOTION TOPICAL 0.75% |
4 |
Tier 4 |
25% | 25% | 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 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 |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
METRONIDAZOLE VAGINAL GEL |
4 |
Tier 4 |
25% | 25% | None |
METRONIDAZOLE VAGINAL GEL 0.75% |
4 |
Tier 4 |
25% | 25% | Q:70 /15Days |
MEXILETINE 150MG CAPSULE |
2 |
Tier 2 |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 200MG CAPSULE |
2 |
Tier 2 |
$25.00 | $75.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Tier 2 |
$25.00 | $75.00 | None |
MIACALCIN 200IU/ML VIAL |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MIACALCIN 200UNITS NASAL SPRA |
4 |
Tier 4 |
25% | 25% | Q:4 /30Days |
MICARDIS 20MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MICARDIS 40MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MICARDIS 80MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MICARDIS HCT 40/12.5MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MICARDIS HCT 80/12.5MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MICARDIS HCT 80/25MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MICROZIDE 12.5MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $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 |
MILLIPRED TABLETS 5MG |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINIPRESS 1MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MINIPRESS 2MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MINIPRESS 5MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MINOCIN PELLET FILLED CAPSULES 100MG (50 CT) |
4 |
Tier 4 |
25% | 25% | None |
MINOCIN PELLET FILLED CAPSULES 50MG (100 CT) |
4 |
Tier 4 |
25% | 25% | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOCYCLINE 50MG CAPSULE |
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 |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MIRAPEX 0.125MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MIRAPEX 0.25MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MIRAPEX 0.5MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MIRAPEX 0.75MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MIRAPEX 1.5MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
MIRAPEX 1MG TABLET |
4 |
Tier 4 |
25% | 25% | S |
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 |
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 |
$5.00 | $15.00 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
$5.00 | $15.00 | None |
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 | P |
MOBIC 15MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MOBIC 7.5MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MOEXIPRIL HCL 15MG 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 |
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 |
MONODOX 100MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MONODOX 50MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MONOKET 10MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MONOPRIL 10MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONOPRIL 40MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MORPHINE SULFATE 100MG TABLET SA |
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 SA |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MS CONTIN 100MG TABLET SA |
4 |
Tier 4 |
25% | 25% | None |
MS CONTIN 15MG TABLET 100 EA |
4 |
Tier 4 |
25% | 25% | None |
MS CONTIN 200MG TABLET SA |
4 |
Tier 4 |
25% | 25% | None |
MS CONTIN 30MG TABLET SA |
4 |
Tier 4 |
25% | 25% | None |
MS CONTIN 60MG TABLET SA |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
MYAMBUTOL 100MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MYCAMINE 50MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
MYCAMINE FOR INJECTION SOLUTION |
5 |
Tier 5 |
25% | 25% | P |
MYCOBUTIN 150MG CAPSULE |
3 |
Tier 3 |
$45.00 | $135.00 | None |
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | P |
MYDRIACYL 1% EYE DROPS |
4 |
Tier 4 |
25% | 25% | Q:15 /15Days |
MYFORTIC 180MG TABLET |
3 |
Tier 3 |
$45.00 | $135.00 | P |
MYFORTIC 360MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
4 |
Tier 4 |
25% | 25% | None |