2012 Medicare Part D Plan Formulary Information |
HumanaChoice R5826-009 (Regional PPO) (R5826-009-0)
Benefit Details
|
The HumanaChoice R5826-009 (Regional PPO) (R5826-009-0) Formulary Drugs Starting with the Letter M in Statewide County, WI: CMS MA Region 14 which includes: WI IL
|
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 |
25% | 25% | None |
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR |
1 |
Tier 1 |
25% | 25% | None |
MAGNESIUM SULFATE 4% IV SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
MAGNESIUM SULFATE 8% IV SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
Tier 1 |
25% | 25% | None |
MALARONE 250-100MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MALARONE 62.5-25MG PED TABLET |
3 |
Tier 3 |
25% | 25% | None |
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
MAPROTILINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MAPROTILINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAPROTILINE 75MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MARGESIC H 5MG-500MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:240 /30Days |
MARLISSA-28 TABLET |
1 |
Tier 1 |
25% | 25% | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Tier 3 |
25% | 25% | None |
MATULANE 50MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
MAVIK 1MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MAVIK 2MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MAVIK 4MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MAXAIR AUTOHALER 0.2 MG AERO |
3 |
Tier 3 |
25% | 25% | Q:14 /30Days |
MAXALT 10MG TABLET 12 CRTN |
3 |
Tier 3 |
25% | 25% | Q:12 /30Days |
MAXALT 5MG TABLET 12 CRTN |
3 |
Tier 3 |
25% | 25% | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
3 |
Tier 3 |
25% | 25% | Q:12 /30Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
3 |
Tier 3 |
25% | 25% | Q:12 /30Days |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
3 |
Tier 3 |
25% | 25% | None |
MAXIDONE 10/750MG TABLET |
3 |
Tier 3 |
25% | 25% | Q:150 /30Days |
MAXITROL EYE OINTMENT |
3 |
Tier 3 |
25% | 25% | None |
MAXITROL SUS 0.1% OP |
3 |
Tier 3 |
25% | 25% | None |
MAXZIDE 37.5 MG-25 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MAXZIDE 50; 75mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
25% | 25% | None |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLOFENAMATE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MEDROL 16MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MEDROL 32MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MEDROL 4MG DOSEPAK |
3 |
Tier 3 |
25% | 25% | P |
MEDROL 4MG DOSEPAK (100 CT) |
3 |
Tier 3 |
25% | 25% | P |
MEDROL 8MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
25% | 25% | Q:1 /90Days |
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 |
25% | 25% | None |
MEGACE ES 625MG/5ML SUSP |
3 |
Tier 3 |
25% | 25% | None |
MEGESTROL 20MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
2 |
Tier 2 |
25% | 25% | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Tier 2 |
25% | 25% | None |
Meloxicam 15mg/1 |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Meloxicam 7.5mg 500 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
25% | 25% | Q:300 /30Days |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
3 |
Tier 3 |
25% | 25% | None |
MENEST 0.3MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.625MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MENEST 1.25MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MENEST 2.5MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Tier 3 |
25% | 25% | None |
MENOSTAR 14 MCG/DAY PATCH |
3 |
Tier 3 |
25% | 25% | Q:8 /28Days |
MENTAX 1% CREAM 15G TUBE |
3 |
Tier 3 |
25% | 25% | None |
MENVEO INJECTION KIT |
3 |
Tier 3 |
25% | 25% | None |
MEPRON 750MG/5ML ORAL SUSP |
4 |
Tier 4 |
25% | 25% | None |
MERCAPTOPURINE 50MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MEROPENEM FOR INJECTION |
2 |
Tier 2 |
25% | 25% | None |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mesalamine 4g/60mL 7 BOTTLE, UNIT-DOSE in 1 CARTON / 60 mL in 1 BOTTLE, UNIT-DOSE |
2 |
Tier 2 |
25% | 25% | Q:1800 /30Days |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
3 |
Tier 3 |
25% | 25% | P |
MESNEX 400MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MESNEX INJECTION |
4 |
Tier 4 |
25% | 25% | P |
MESTINON 180MG TIMESPAN |
3 |
Tier 3 |
25% | 25% | None |
METAPROTERENOL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METAPROTERENOL 20MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
METAXALONE 800 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL 850MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
METFORMIN HYDROCHLORIDE 750mg/1 |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Methadone Hydrochloride 10mg/5mL |
1 |
Tier 1 |
25% | 25% | None |
Methadone Hydrochloride 10mg/mL |
1 |
Tier 1 |
25% | 25% | None |
Methadone Hydrochloride 5mg/5mL |
1 |
Tier 1 |
25% | 25% | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
Tier 1 |
25% | 25% | None |
METHADOSE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHADOSE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHAMPHETAMINE HYDROCHLORIDE TABLETS 5 MG |
2 |
Tier 2 |
25% | 25% | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Methenamine Hippurate 1g/1 |
3 |
Tier 3 |
25% | 25% | None |
METHERGINE 0.2MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Methimazole 10mg/1 |
1 |
Tier 1 |
25% | 25% | None |
METHIMAZOLE TABLETS |
1 |
Tier 1 |
25% | 25% | None |
Methocarbamol 500mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | P |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | P |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
25% | 25% | 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 |
25% | 25% | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT |
2 |
Tier 2 |
25% | 25% | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLDOPA 250MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLDOPA 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHYLDOPATE 250MG/5ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
Methylergonovine Maleate 0.2mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | P |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLPREDNISOLONE 1GM VIAL |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Tier 1 |
25% | 25% | None |
Methylprednisolone 4mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | P |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Tier 1 |
25% | 25% | P |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
25% | 25% | P |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Tier 1 |
25% | 25% | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
METROCREAM 0.75% CREAM |
3 |
Tier 3 |
25% | 25% | P |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
25% | 25% | None |
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG |
3 |
Tier 3 |
25% | 25% | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
METRONIDAZOLE VAGINAL GEL |
1 |
Tier 1 |
25% | 25% | None |
MEXILETINE 150MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MEXILETINE 200MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MEXILETINE 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MICONAZOLE 3 200MG SUPPOS. |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN 1-0.02MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Tier 1 |
25% | 25% | None |
MICROGESTIN FE 1/20 TABLET |
1 |
Tier 1 |
25% | 25% | None |
MICROZIDE 12.5MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
MIDODRINE HCL 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIDODRINE HCL 2.5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
3 |
Tier 3 |
25% | 25% | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
25% | 25% | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
25% | 25% | Q:8 /30Days |
MINIPRESS 1MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Minipress 2mg/1 250 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
Minipress 5mg/1 250 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Minocycline Hydrochloride 100mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Minocycline Hydrochloride 75mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Mirtazapine 15mg/1 1000 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
mirtazapine 45mg/1 1000 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Mirtazapine 7.5mg/1 |
2 |
Tier 2 |
25% | 25% | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
MISOPROSTOL 100MCG TABLET |
2 |
Tier 2 |
25% | 25% | None |
MISOPROSTOL 200MCG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL |
2 |
Tier 2 |
25% | 25% | P |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Tier 2 |
25% | 25% | P |
Modicon 6 DIALPACK in 1 CARTON / 1 KIT in 1 DIALPACK |
3 |
Tier 3 |
25% | 25% | None |
MOEXIPRIL HCL 15MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Mometasone Furoate 1mg/g |
1 |
Tier 1 |
25% | 25% | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONOKET 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
1 |
Tier 1 |
25% | 25% | None |
MONUROL PAK GRANULES 3 GM |
3 |
Tier 3 |
25% | 25% | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE ER 100 MG CAP |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 20 MG CAP |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 50 MG CAP |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 80 MG CAP |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE TABLETS |
2 |
Tier 2 |
25% | 25% | None |
MORPHINE SULFATE TABLETS |
2 |
Tier 2 |
25% | 25% | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
MOZOBIL SOLUTION 24MG/1.2ML |
4 |
Tier 4 |
25% | 25% | P Q:8 /30Days |
Multaq 400mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
MUSTARGEN 10MG VIAL |
3 |
Tier 3 |
25% | 25% | P |
MYAMBUTOL 100MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MYCAMINE 50MG VIAL |
4 |
Tier 4 |
25% | 25% | None |
MYCAMINE FOR INJECTION SOLUTION |
4 |
Tier 4 |
25% | 25% | None |
MYCOBUTIN 150MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
Mycophenolate Mofetil 250mg/1 |
1 |
Tier 1 |
25% | 25% | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYDRIACYL 1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
MYFORTIC 180MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
MYFORTIC 360MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
MYOZYME 50MG VIAL |
4 |
Tier 4 |
25% | 25% | P |
MYTELASE 10MG CAPLET |
3 |
Tier 3 |
25% | 25% | None |