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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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United American - Select (PDP) (S5755-080-0)
Tier 1 (174)
Tier 2 (1775)
Tier 3 (830)
Tier 4 (207)
Tier 5 (228)
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2012 Medicare Part D Plan Formulary Information
United American - Select (PDP) (S5755-080-0)
Benefit Details           
The United American - Select (PDP) (S5755-080-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 9 which includes: SC
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 Drugs $45.00$122.00None
Macrodantin Nitrofurantion crystals 25mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   3 Preferred Brand Drugs $45.00$122.00None
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR   3 Preferred Brand Drugs $45.00$122.00None
MAGNESIUM SULFATE 4% IV SOLUTION   3 Preferred Brand Drugs $45.00$122.00None
MAGNESIUM SULFATE 8% IV SOLUTION   3 Preferred Brand Drugs $45.00$122.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   2 Non-Preferred Generic Drugs $8.00$21.00None
MALARONE 250-100MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
MALARONE 62.5-25MG PED TABLET   3 Preferred Brand Drugs $45.00$122.00None
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
MAPROTILINE 25MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAPROTILINE 50MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MAPROTILINE 75MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MARGESIC H 5MG-500MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MARLISSA-28 TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MARPLAN 10MG TABLET (100 CT)   3 Preferred Brand Drugs $45.00$122.00None
MATULANE 50MG CAPSULE   5 Specialty Tier Drugs 25%25%None
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00None
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00None
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00None
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00None
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00None
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 Preferred Brand Drugs $45.00$122.00Q:54
/90Days
MAXALT MLT 5MG TABLET 4X3 UNIT CASE   3 Preferred Brand Drugs $45.00$122.00Q:54
/90Days
MEBENDAZOLE 100MG TABLET CHEW   2 Non-Preferred Generic Drugs $8.00$21.00None
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT   2 Non-Preferred Generic Drugs $8.00$21.00None
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT   2 Non-Preferred Generic Drugs $8.00$21.00None
MECLOFENAMATE 100MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MECLOFENAMATE 50MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MEDROXYPROGESTERONE 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MEDROXYPROGESTERONE 2.5MG   2 Non-Preferred Generic Drugs $8.00$21.00None
MEDROXYPROGESTERONE 5MG TABLET   1 Preferred Generic Drugs $2.00$0.00None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEFENAMIC ACID CAPSULES   2 Non-Preferred Generic Drugs $8.00$21.00None
MEFLOQUINE HCL 250MG TABLET 25 BOT   2 Non-Preferred Generic Drugs $8.00$21.00None
MEGACE ES 625MG/5ML SUSP   3 Preferred Brand Drugs $45.00$122.00Q:150
/30Days
MEGESTROL 20MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL   2 Non-Preferred Generic Drugs $8.00$21.00None
MEGESTROL ACETATE 40MG TABLET (250 CT)   2 Non-Preferred Generic Drugs $8.00$21.00None
Meloxicam 15mg/1   2 Non-Preferred Generic Drugs $8.00$21.00None
Meloxicam 7.5mg 500 TABLET BOTTLE   1 Preferred Generic Drugs $2.00$0.00None
MELOXICAM 7.5MG/5ML SUSPENSION ORAL   2 Non-Preferred Generic Drugs $8.00$21.00None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   2 Non-Preferred Generic Drugs $8.00$21.00None
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR   3 Preferred Brand Drugs $45.00$122.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MENEST 0.3MG TABLET   4 Non-Preferred Brand Drugs $95.00$257.00None
MENEST 0.625MG TABLET   4 Non-Preferred Brand Drugs $95.00$257.00None
MENEST 1.25MG TABLET   4 Non-Preferred Brand Drugs $95.00$257.00None
MENEST 2.5MG TABLET   4 Non-Preferred Brand Drugs $95.00$257.00None
MENOMUNE-A/C/Y/W-135 VIAL   3 Preferred Brand Drugs $45.00$122.00None
MENOSTAR 14 MCG/DAY PATCH   4 Non-Preferred Brand Drugs $95.00$257.00None
MENVEO INJECTION KIT   3 Preferred Brand Drugs $45.00$122.00None
MEPRON 750MG/5ML ORAL SUSP   5 Specialty Tier Drugs 25%25%None
MERCAPTOPURINE 50MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MEROPENEM FOR INJECTION   2 Non-Preferred Generic Drugs $8.00$21.00None
Mesalamine 4g/60mL 7 BOTTLE, UNIT-DOSE in 1 CARTON / 60 mL in 1 BOTTLE, UNIT-DOSE   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN   2 Non-Preferred Generic Drugs $8.00$21.00None
MESNEX 400MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
MESTINON 180MG TIMESPAN   3 Preferred Brand Drugs $45.00$122.00None
MESTINON 60MG/5ML SYRUP   3 Preferred Brand Drugs $45.00$122.00None
METADATE CD 20MG CAPSULE   4 Non-Preferred Brand Drugs $95.00$257.00P
Metadate CD 30mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand Drugs $95.00$257.00P
METADATE CD 40MG CAPSULE   4 Non-Preferred Brand Drugs $95.00$257.00P
METADATE CD 50MG CAPSULE   4 Non-Preferred Brand Drugs $95.00$257.00P
METADATE CD 60MG CAPSULE   4 Non-Preferred Brand Drugs $95.00$257.00P
METAPROTERENOL 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METAPROTERENOL 20MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00None
METFORMIN HCL 1000MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $8.00$21.00Q:180
/90Days
METFORMIN HCL 500MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $8.00$21.00Q:360
/90Days
METFORMIN HCL 850MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00Q:270
/90Days
METFORMIN HCL ER 500MG TABLET SR 24HR   1 Preferred Generic Drugs $2.00$0.00Q:450
/90Days
METFORMIN HYDROCHLORIDE 750mg/1   2 Non-Preferred Generic Drugs $8.00$21.00Q:270
/90Days
METHADONE HCL 5MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $8.00$21.00None
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
Methadone Hydrochloride 10mg/5mL   2 Non-Preferred Generic Drugs $8.00$21.00None
Methadone Hydrochloride 10mg/mL   2 Non-Preferred Generic Drugs $8.00$21.00None
Methadone Hydrochloride 5mg/5mL   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHADONE HYDROCHLORIDE INJECTION 10MG/ML   2 Non-Preferred Generic Drugs $8.00$21.00None
METHADOSE 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METHADOSE 5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METHAZOLAMIDE 25MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METHAZOLAMIDE 50MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
Methenamine Hippurate 1g/1   2 Non-Preferred Generic Drugs $8.00$21.00None
METHERGINE 0.2MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
Methimazole 10mg/1   2 Non-Preferred Generic Drugs $8.00$21.00None
METHIMAZOLE TABLETS   2 Non-Preferred Generic Drugs $8.00$21.00None
METHOTREXATE 2.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
METHOTREXATE FOR INJECTION 1 GM/ML   4 Non-Preferred Brand Drugs $95.00$257.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHOTREXATE INJECTION 25 MG/ML   2 Non-Preferred Generic Drugs $8.00$21.00None
METHYCLOTHIAZIDE 5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
Methylergonovine Maleate 0.2mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
METHYLIN 10MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLIN 20MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLIN TABLET 5MG (100 CT)   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPHENIDATE 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPHENIDATE 20MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPHENIDATE 5MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPHENIDATE ER 20 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPHENIDATE ER 30 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE ER 40 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00P
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00P
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPREDNISOLONE 16MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
METHYLPREDNISOLONE 1GM VIAL   3 Preferred Brand Drugs $45.00$122.00None
METHYLPREDNISOLONE 32MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE   2 Non-Preferred Generic Drugs $8.00$21.00None
Methylprednisolone 4mg/1 100 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $2.00$0.00P
METHYLPREDNISOLONE 8 MG ORAL TABLET   2 Non-Preferred Generic Drugs $8.00$21.00P
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS   2 Non-Preferred Generic Drugs $8.00$21.00None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL   2 Non-Preferred Generic Drugs $8.00$21.00None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   1 Preferred Generic Drugs $2.00$0.00None
METIPRANOLOL 0.3% EYE DROPS   2 Non-Preferred Generic Drugs $8.00$21.00None
METOCLOPRAMIDE 5 MG TABLET   1 Preferred Generic Drugs $2.00$0.00None
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL   2 Non-Preferred Generic Drugs $8.00$21.00None
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL   1 Preferred Generic Drugs $2.00$0.00None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT   2 Non-Preferred Generic Drugs $8.00$21.00None
METOLAZONE 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METOLAZONE 2.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METOLAZONE 5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL SUCCINATE 25MG TABLET SR 24HR   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL SUCCINATE 50MG TABLET SR 24HR   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1 Preferred Generic Drugs $2.00$0.00None
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Preferred Generic Drugs $2.00$0.00None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1 Preferred Generic Drugs $2.00$0.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
METROGEL TOPICAL 1% GEL   3 Preferred Brand Drugs $45.00$122.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 0.75% CREAM   2 Non-Preferred Generic Drugs $8.00$21.00None
METRONIDAZOLE 0.75% LOTION   2 Non-Preferred Generic Drugs $8.00$21.00None
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG   2 Non-Preferred Generic Drugs $8.00$21.00None
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL   2 Non-Preferred Generic Drugs $8.00$21.00None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL   2 Non-Preferred Generic Drugs $8.00$21.00None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   2 Non-Preferred Generic Drugs $8.00$21.00None
METRONIDAZOLE VAGINAL GEL   2 Non-Preferred Generic Drugs $8.00$21.00None
MEXILETINE 150MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MEXILETINE 200MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MEXILETINE 250MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Micardis 20mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK   3 Preferred Brand Drugs $45.00$122.00Q:90
/90Days
MICARDIS 40MG TABLET   3 Preferred Brand Drugs $45.00$122.00Q:90
/90Days
MICARDIS 80MG TABLET   3 Preferred Brand Drugs $45.00$122.00Q:180
/90Days
MICARDIS HCT 40/12.5MG TABLET   3 Preferred Brand Drugs $45.00$122.00Q:90
/90Days
MICARDIS HCT 80/12.5MG TABLET   3 Preferred Brand Drugs $45.00$122.00Q:90
/90Days
MICARDIS HCT 80/25MG TABLET   3 Preferred Brand Drugs $45.00$122.00Q:90
/90Days
MICONAZOLE 3 200MG SUPPOS.   2 Non-Preferred Generic Drugs $8.00$21.00None
MICROGESTIN 1-0.02MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MICROGESTIN 1.5-0.03MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MICROGESTIN FE 1.5/30 TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MICROGESTIN FE 1/20 TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIDODRINE HCL 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MIDODRINE HCL 2.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MIDODRINE HCL 5MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $8.00$21.00None
MIGERGOT 2-100MG SUPPOSITORY RECTAL   2 Non-Preferred Generic Drugs $8.00$21.00None
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP   4 Non-Preferred Brand Drugs $95.00$257.00Q:24
/90Days
MINOCYCLINE 100MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOCYCLINE 50MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOCYCLINE HCL 75MG CAPSULE   2 Non-Preferred Generic Drugs $8.00$21.00None
Minocycline Hydrochloride 100mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
Minocycline Hydrochloride 75mg/1 100 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOXIDIL 10MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MINOXIDIL 2.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MIRAPEX ER 0.375mg/1 1 BOTTLE, PLASTIC in 1 CARTON / 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTI   3 Preferred Brand Drugs $45.00$122.00None
MIRAPEX ER 0.75 MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
MIRAPEX ER 1.5 MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
MIRAPEX ER 2.25mg/1 ER 30 TABLET   3 Preferred Brand Drugs $45.00$122.00None
MIRAPEX ER 3 MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
MIRAPEX ER 3.75mg/1 ER 30 TABLET   3 Preferred Brand Drugs $45.00$122.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRAPEX ER 4.5 MG TABLET   3 Preferred Brand Drugs $45.00$122.00None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
Mirtazapine 15mg/1 1000 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
mirtazapine 45mg/1 1000 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
Mirtazapine 7.5mg/1   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
MIRTAZAPINE TABLET 30MG (30 CT)   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
MISOPROSTOL 100MCG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MISOPROSTOL 200MCG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MITOXANTRONE INJECTION 2MG 125ML VIAL   2 Non-Preferred Generic Drugs $8.00$21.00None
MOEXIPRIL HCL 15MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MOEXIPRIL HCL 7.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00Q:180
/90Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   2 Non-Preferred Generic Drugs $8.00$21.00Q:90
/90Days
Mometasone Furoate 1mg/g   2 Non-Preferred Generic Drugs $8.00$21.00None
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE   2 Non-Preferred Generic Drugs $8.00$21.00None
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%   2 Non-Preferred Generic Drugs $8.00$21.00None
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE 100MG TABLET SA   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE 15MG TABLET SA   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE 200MG TABLET SA   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE 30MG TABLET SA   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ER 100 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ER 20 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ER 30 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ER 50 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ER 60 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ER 80 MG CAP   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL   2 Non-Preferred Generic Drugs $8.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ORAL SOLUTION   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE ORAL SOLUTION   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE TABLET ER 60MG (100 CT)   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE TABLETS   2 Non-Preferred Generic Drugs $8.00$21.00None
MORPHINE SULFATE TABLETS   2 Non-Preferred Generic Drugs $8.00$21.00None
MOZOBIL SOLUTION 24MG/1.2ML   5 Specialty Tier Drugs 25%25%Q:5
/90Days
Multaq 400mg/1 60 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$122.00None
MUPIROCIN 2% OINTMENT   2 Non-Preferred Generic Drugs $8.00$21.00None
MUSTARGEN 10MG VIAL   4 Non-Preferred Brand Drugs $95.00$257.00None
MYCOBUTIN 150MG CAPSULE   3 Preferred Brand Drugs $45.00$122.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Mycophenolate Mofetil 250mg/1   2 Non-Preferred Generic Drugs $8.00$21.00P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT   2 Non-Preferred Generic Drugs $8.00$21.00P
MYFORTIC 180MG TABLET   3 Preferred Brand Drugs $45.00$122.00P
MYFORTIC 360MG TABLET   3 Preferred Brand Drugs $45.00$122.00P
MYTELASE 10MG CAPLET   3 Preferred Brand Drugs $45.00$122.00None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D United American - Select (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $320 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2012 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.