2012 Medicare Part D Plan Formulary Information |
WellCare Classic (PDP) (S5967-162-0)
Benefit Details
|
The WellCare Classic (PDP) (S5967-162-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
|
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 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MAPROTILINE 25MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MAPROTILINE 50MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MAPROTILINE 75MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MATULANE 50MG CAPSULE |
4 |
Specialty Tier Drugs |
25% | N/A | None |
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MEBENDAZOLE 100MG TABLET CHEW |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MEGESTROL 20MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Meloxicam 15mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Meloxicam 7.5mg 500 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MENEST 0.3MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MENEST 0.625MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MENEST 1.25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MENEST 2.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MENVEO INJECTION KIT |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Meprobamate 200mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
Meprobamate 400mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
MEPRON 750MG/5ML ORAL SUSP |
4 |
Specialty Tier Drugs |
25% | N/A | None |
MERCAPTOPURINE 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
Mesalamine 4g/60mL 7 BOTTLE, UNIT-DOSE in 1 CARTON / 60 mL in 1 BOTTLE, UNIT-DOSE |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MESNEX 400MG TABLET |
4 |
Specialty Tier Drugs |
25% | N/A | None |
MESTINON 180MG TIMESPAN |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MESTINON 60MG/5ML SYRUP |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METADATE ER 20MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METAPROTERENOL 10MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 20MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:78 /31Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:155 /31Days |
METFORMIN HCL 850MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:93 /31Days |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:124 /31Days |
METFORMIN HYDROCHLORIDE 750mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:77 /31Days |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
METHADOSE 10MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
METHADOSE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHAZOLAMIDE 25MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Methenamine Hippurate 1g/1 |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
Methimazole 10mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHIMAZOLE TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHITEST 10MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
Methocarbamol 500mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
METHOCARBAMOL 750MG TABLET (500 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
METHOTREXATE 2.5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | P |
METHOTREXATE INJECTION 25 MG/ML |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLDOPA 250MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLDOPA 500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLIN 10MG TABLET (100 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLIN 20MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLIN ER 10MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLIN ER 20MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLIN TABLET 5MG (100 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPHENIDATE 10MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPHENIDATE 20MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPHENIDATE 5MG TABLET (100 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 1GM VIAL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylprednisolone 4mg/1 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 10MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOLAZONE 2.5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOLAZONE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MEXILETINE 150MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MEXILETINE 200MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MEXILETINE 250MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MIACALCIN 200IU/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
MICROGESTIN 1-0.02MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN FE 1.5/30 TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MICROGESTIN FE 1/20 TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MIDODRINE HCL 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MIDODRINE HCL 2.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MILLIPRED TABLETS 5MG |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MINOXIDIL 10MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Mirtazapine 15mg/1 1000 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
mirtazapine 45mg/1 1000 TABLET, FILM COATED in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Mirtazapine 7.5mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MISOPROSTOL 100MCG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MISOPROSTOL 200MCG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
MOEXIPRIL HCL 15MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOEXIPRIL HCL 7.5MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Mometasone Furoate 1mg/g |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:248 /31Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:248 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:248 /31Days |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:248 /31Days |
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:248 /31Days |
MORPHINE SULFATE TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
MORPHINE SULFATE TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Multaq 400mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
MUPIROCIN 2% OINTMENT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
MYCAMINE 50MG VIAL |
4 |
Specialty Tier Drugs |
25% | N/A | P |
MYCAMINE FOR INJECTION SOLUTION |
4 |
Specialty Tier Drugs |
25% | N/A | P |
MYCOBUTIN 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
Mycophenolate Mofetil 250mg/1 |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
MYFORTIC 180MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
MYFORTIC 360MG TABLET |
3 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
MYOZYME 50MG VIAL |
4 |
Specialty Tier Drugs |
25% | N/A | P |