2013 Medicare Part D Plan Formulary Information |
United American - Select (PDP) (S5755-074-0)
Benefit Details
|
The United American - Select (PDP) (S5755-074-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 2 which includes: CT MA RI VT
|
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 Name Drugs |
$40.00 | $122.00 | None |
Macrodantin Nitrofurantion crystals 25mg 100 CAPSULE BOTTLE |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
mafenide acetate 50 gm powd pk |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MALARONE 250-100MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MALARONE 62.5-25MG PED TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MAPROTILINE 25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARLISSA-28 TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MATULANE 50MG CAPSULE |
5 |
Specialty Drugs |
25% | 25% | None |
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MECLOFENAMATE 100MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLOFENAMATE 50MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
Mefenamic Acid 250mg/1 30 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEGACE ES 625MG/5ML SUSP |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | Q:150 /30Days |
MEGESTROL 20MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Meloxicam 15mg/1 |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
MELOXICAM 7.5 MG TABLET |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | None |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | None |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | None |
MENEST 2.5MG TABLET |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MENVEO INJECTION KIT |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEPRON 750MG/5ML ORAL SUSP |
5 |
Specialty Drugs |
25% | 25% | None |
MERCAPTOPURINE 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEROPENEM FOR INJECTION |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MESNEX 400MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MESTINON 180MG TIMESPAN |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MESTINON 60MG/5ML SYRUP |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
METADATE CD 20MG CAPSULE |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | P |
Metadate CD 30mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | P |
METADATE CD 40MG CAPSULE |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | P |
METADATE CD 50MG CAPSULE |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METADATE CD 60MG CAPSULE |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | P |
METAPROTERENOL 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:180 /90Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:450 /90Days |
METFORMIN HCL ER 1,000 MG TAB |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:180 /90Days |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:450 /90Days |
Metformin Hydrochloride 750mg/1 |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:270 /90Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:270 /90Days |
METHADONE HCL 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methadone Hydrochloride 10mg/5mL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methadone Hydrochloride 10mg/mL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methadone Hydrochloride 5mg/5mL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHADOSE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHAZOLAMIDE 25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methenamine Hippurate 1g/1 |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHERGINE 0.2MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
Methimazole 10mg/1 |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHIMAZOLE TABLETS |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHOTREXATE 2.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
Methotrexate 25mg/mL 10 VIAL in 1 BOX, UNIT-DOSE / 8 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHYLPHENIDATE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPHENIDATE 20MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPHENIDATE ER 20 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPHENIDATE ER 30 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPHENIDATE ER 40 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
methylprednisolone 125 mg vial |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPREDNISOLONE 32MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
methylprednisolone 40 mg vial |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylprednisolone Sodium Succinate 1g/8mL 1 VIAL, SINGLE-DOSE in 1 BOX / 8 mL in 1 VIAL, SINGLE-DO |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
METOLAZONE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOLAZONE 2.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOLAZONE 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METROGEL TOPICAL 1% GEL |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
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 |
$4.00 | $24.00 | None |
METRONIDAZOLE 0.75% LOTION |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
METRONIDAZOLE VAGINAL GEL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEXILETINE 150MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEXILETINE 200MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
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 Name Drugs |
$40.00 | $122.00 | Q:90 /90Days |
MICARDIS 40MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | Q:90 /90Days |
MICARDIS 80MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | Q:180 /90Days |
MICARDIS HCT 40/12.5MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | Q:90 /90Days |
MICARDIS HCT 80/12.5MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | Q:90 /90Days |
MICARDIS HCT 80/25MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | Q:90 /90Days |
MICONAZOLE 3 200MG SUPPOS. |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MICROGESTIN 1-0.02MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MICROGESTIN 1.5-0.03MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MICROGESTIN FE 1.5/30 TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MICROGESTIN FE 1/20 TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
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 |
$4.00 | $24.00 | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | Q:24 /90Days |
MINOCYCLINE 100MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MINOCYCLINE 50MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
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 |
$4.00 | $24.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MINOXIDIL 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MIRAPEX ER 0.375mg/1 1 BOTTLE, PLASTIC in 1 CARTON / 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTI |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MIRAPEX ER 0.75 MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MIRAPEX ER 1.5 MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MIRAPEX ER 2.25mg/1 ER 30 TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MIRAPEX ER 3 MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
MIRAPEX ER 3.75mg/1 ER 30 TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
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 Name Drugs |
$40.00 | $122.00 | None |
MIRTAZAPINE 15 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
Mirtazapine 7.5mg/1 |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
misoprostol 100 mcg tablet |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
misoprostol 200 mcg tablet |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
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 |
$4.00 | $24.00 | None |
MODAFINIL 100 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P Q:90 /90Days |
MODAFINIL 200 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P Q:90 /90Days |
MOEXIPRIL HCL 15MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MOEXIPRIL HCL 7.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:180 /90Days |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Mometasone Furoate 1mg/g 45 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MONTELUKAST SOD 10 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
montelukast sod 4 mg granules |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
montelukast sod 4 mg tab chew |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
montelukast sod 5 mg tab chew |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | Q:90 /90Days |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ER 100 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 20 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ER 50 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ER 80 MG CAP |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE TABLETS |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MORPHINE SULFATE TABLETS |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MOZOBIL SOLUTION 24MG/1.2ML |
5 |
Specialty Drugs |
25% | 25% | Q:5 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
mupirocin 2% cream |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MUPIROCIN 2% OINTMENT |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MUSTARGEN 10MG VIAL |
4 |
Non-Preferred Brand Name Drugs |
$95.00 | $257.00 | None |
MYCOBUTIN 150MG CAPSULE |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | P |
MYFORTIC 180MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | P |
MYFORTIC 360MG TABLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | P |
MYORISAN 10 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MYORISAN 20 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYORISAN 40 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$4.00 | $24.00 | None |
MYTELASE 10MG CAPLET |
3 |
Preferred Brand Name Drugs |
$40.00 | $122.00 | None |