2013 Medicare Part D Plan Formulary Information |
Medica Prime Solution Basic with Part D Option 1 (Cost) (H2450-016-0)
Benefit Details
|
The Medica Prime Solution Basic with Part D Option 1 (Cost) (H2450-016-0) Formulary Drugs Starting with the Letter M in LAWRENCE County, SD: CMS MA Region 19 which includes: SD
|
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 |
Tier 2 |
25% | 25% | None |
Macrobid 25; 75mg/1; mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | P Q:90 /365Days |
Macrodantin Nitrofurantion crystals 100mg 100 CAPSULE BOTTLE |
3 |
Tier 3 |
25% | 25% | P Q:90 /365Days |
Macrodantin Nitrofurantion crystals 25mg 100 CAPSULE BOTTLE |
3 |
Tier 3 |
25% | 25% | P Q:90 /365Days |
mafenide acetate 50 gm powd pk |
1 |
Tier 1 |
25% | 25% | None |
Magnacet 400; 10mg/1; mg/1 |
3 |
Tier 3 |
25% | 25% | Q:300 /30Days |
MAGNACET 5 MG-400 MG TABLET |
3 |
Tier 3 |
25% | 25% | Q:300 /30Days |
MAGNACET 7.5 MG-400 MG TABLET |
3 |
Tier 3 |
25% | 25% | Q:300 /30Days |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
Tier 1 |
25% | 25% | None |
MALARONE 250-100MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
MAPROTILINE 75MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Marinol 10mg/1 60 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
MARINOL 2.5MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
MARINOL 5MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
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 |
MAXALT 10mg/1 18 POUCH in 1 CARTON / 1 TABLET in 1 POUCH |
3 |
Tier 3 |
25% | 25% | Q:18 /28Days |
MAXALT 5mg/1 18 POUCH in 1 CARTON / 1 TABLET in 1 POUCH |
3 |
Tier 3 |
25% | 25% | Q:18 /28Days |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
3 |
Tier 3 |
25% | 25% | Q:18 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
3 |
Tier 3 |
25% | 25% | Q:18 /28Days |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
3 |
Tier 3 |
25% | 25% | None |
MAXIDONE 10-750 MG 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 100 TABLET BOTTLE |
3 |
Tier 3 |
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 |
MECLOFENAMATE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
25% | 25% | Q:1 /84Days |
Mefenamic Acid 250mg/1 30 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGACE 40MG/ML ORAL SUSP |
3 |
Tier 3 |
25% | 25% | None |
MEGACE ES 625MG/5ML SUSP |
2 |
Tier 2 |
25% | 25% | None |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
25% | 25% | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Meloxicam 15mg/1 |
1 |
Tier 1 |
25% | 25% | None |
MELOXICAM 7.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
25% | 25% | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
4 |
Tier 4 |
25% | 25% | 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 |
2 |
Tier 2 |
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 |
2 |
Tier 2 |
25% | 25% | None |
MENOSTAR 14 MCG/DAY PATCH |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
MENTAX 1% CREAM 15G TUBE |
3 |
Tier 3 |
25% | 25% | None |
MENVEO INJECTION KIT |
2 |
Tier 2 |
25% | 25% | None |
MEPRON 750MG/5ML ORAL SUSP |
4 |
Tier 4 |
25% | 25% | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MEROPENEM FOR INJECTION |
1 |
Tier 1 |
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 1 KIT in 1 CARTON |
1 |
Tier 1 |
25% | 25% | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
1 |
Tier 1 |
25% | 25% | None |
MESNEX 400MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
MESNEX INJECTION |
3 |
Tier 3 |
25% | 25% | None |
MESTINON 180MG TIMESPAN |
3 |
Tier 3 |
25% | 25% | None |
MESTINON 60MG/5ML SYRUP |
3 |
Tier 3 |
25% | 25% | None |
MESTINON TABLETS 60MG 100 BOT |
3 |
Tier 3 |
25% | 25% | None |
METADATE CD 10MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
METADATE CD 20MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Metadate CD 30mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
METADATE CD 40MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METADATE CD 50MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
METADATE CD 60MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
METADATE ER 20MG TABLET SA |
3 |
Tier 3 |
25% | 25% | Q:90 /30Days |
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 |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
METFORMIN HCL ER 1,000 MG TAB |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
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:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
Methadone Hydrochloride 10mg/5mL |
1 |
Tier 1 |
25% | 25% | Q:1800 /30Days |
Methadone Hydrochloride 10mg/mL |
1 |
Tier 1 |
25% | 25% | Q:1800 /30Days |
Methadone Hydrochloride 5mg/5mL |
1 |
Tier 1 |
25% | 25% | Q:1800 /30Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
Tier 1 |
25% | 25% | None |
METHADOSE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
METHAMPHETAMINE HYDROCHLORIDE TABLETS 5 MG |
1 |
Tier 1 |
25% | 25% | Q:150 /30Days |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METHAZOLAMIDE 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 |
Methenamine Hippurate 1g/1 |
1 |
Tier 1 |
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 |
METHITEST 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
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% | P S |
Methotrexate 25mg/mL 10 VIAL in 1 BOX, UNIT-DOSE / 8 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | P |
METHOTREXATE FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
25% | 25% | P |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
METHYLIN 10 MG CHEWABLE |
3 |
Tier 3 |
25% | 25% | Q:180 /30Days |
METHYLIN 2.5 MG CHEWABLE TAB |
3 |
Tier 3 |
25% | 25% | Q:90 /30Days |
METHYLIN 5 MG CHEWABLE TABLET |
3 |
Tier 3 |
25% | 25% | Q:90 /30Days |
METHYLIN SOLUTION 5MG/5ML 500 ML BOT |
3 |
Tier 3 |
25% | 25% | Q:900 /30Days |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE 2 MG/ML ORAL SOLUTION [METHYLIN] |
3 |
Tier 3 |
25% | 25% | Q:900 /30Days |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE CD 10 MG CAP |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
methylphenidate cd 50 mg cap |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methylphenidate cd 60 mg cap |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 20 MG CAP |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 27 MG TAB |
1 |
Tier 1 |
25% | 25% | Q:31 /31Days |
METHYLPHENIDATE ER 30 MG CAP |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
METHYLPHENIDATE ER 36 MG TAB |
1 |
Tier 1 |
25% | 25% | Q:31 /31Days |
METHYLPHENIDATE ER 40 MG CAP |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 54 MG TAB |
1 |
Tier 1 |
25% | 25% | Q:31 /31Days |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:900 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:900 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methylprednisolone 125 mg vial |
1 |
Tier 1 |
25% | 25% | P |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
methylprednisolone 40 mg vial |
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% | P |
Methylprednisolone 4mg/1 100 TABLET 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% | P |
Methylprednisolone Sodium Succinate 1g/8mL 1 VIAL, SINGLE-DOSE in 1 BOX / 8 mL in 1 VIAL, SINGLE-DO |
1 |
Tier 1 |
25% | 25% | P |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
25% | 25% | P |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOCLOPRAMIDE 10 MG DISINTEGRATING TABLET [METOZOLV] |
3 |
Tier 3 |
25% | 25% | None |
Metoclopramide 10mg/1 |
3 |
Tier 3 |
25% | 25% | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
METOCLOPRAMIDE 5 MG DISINTEGRATING TABLET [METOZOLV] |
3 |
Tier 3 |
25% | 25% | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Metoclopramide 5mg/1 |
3 |
Tier 3 |
25% | 25% | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Tier 1 |
25% | 25% | None |
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 |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METROCREAM 0.75% CREAM |
3 |
Tier 3 |
25% | 25% | None |
METROGEL TOPICAL 1% GEL |
3 |
Tier 3 |
25% | 25% | None |
METROLOTION TOPICAL 0.75% |
3 |
Tier 3 |
25% | 25% | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
25% | 25% | None |
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 |
1 |
Tier 1 |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEVACOR 20MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MEVACOR 40MG TABLET |
3 |
Tier 3 |
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 |
MIACALCIN 200IU/ML VIAL |
2 |
Tier 2 |
25% | 25% | P |
MIACALCIN 200UNITS NASAL SPRA |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
Micardis 20mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK |
3 |
Tier 3 |
25% | 25% | S |
MICARDIS 40MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
MICARDIS 80MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
MICARDIS HCT 40/12.5MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICARDIS HCT 80/12.5MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
MICARDIS HCT 80/25MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
MICONAZOLE 3 200MG SUPPOS. |
1 |
Tier 1 |
25% | 25% | None |
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 |
1 |
Tier 1 |
25% | 25% | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
1 |
Tier 1 |
25% | 25% | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
25% | 25% | Q:8 /28Days |
MILLIPRED 10;5MG;ML |
3 |
Tier 3 |
25% | 25% | None |
MILLIPRED TABLETS 5MG |
3 |
Tier 3 |
25% | 25% | None |
MINIPRESS 1MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
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 |
MINIVELLE 0.0375 MG PATCH |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
MINIVELLE 0.05 MG PATCH |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
MINIVELLE 0.075 MG PATCH |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
MINIVELLE 0.1 MG PATCH |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCIN PELLET FILLED CAPSULES 100MG (50 CT) |
3 |
Tier 3 |
25% | 25% | None |
MINOCIN PELLET FILLED CAPSULES 50MG (100 CT) |
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 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG |
1 |
Tier 1 |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG |
1 |
Tier 1 |
25% | 25% | None |
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 |
MIRAPEX 0.125MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX 0.25MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX 0.5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX 0.75MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX 1.5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX 1MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX ER 0.375mg/1 1 BOTTLE, PLASTIC in 1 CARTON / 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTI |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX ER 0.75 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX ER 1.5 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRAPEX ER 2.25mg/1 ER 30 TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX ER 3 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX ER 3.75mg/1 ER 30 TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRAPEX ER 4.5 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MIRTAZAPINE 15 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
25% | 25% | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
25% | 25% | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Mirtazapine 7.5mg/1 |
1 |
Tier 1 |
25% | 25% | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
25% | 25% | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
misoprostol 100 mcg tablet |
1 |
Tier 1 |
25% | 25% | None |
misoprostol 200 mcg tablet |
1 |
Tier 1 |
25% | 25% | None |
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
MOBIC 15MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MOBIC 7.5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MOBIC 7.5MG/5ML SUSPENSION |
3 |
Tier 3 |
25% | 25% | None |
MODAFINIL 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
MODAFINIL 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Tier 1 |
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 0.1% SOLN |
1 |
Tier 1 |
25% | 25% | None |
Mometasone Furoate 1mg/g 45 g in 1 TUBE |
1 |
Tier 1 |
25% | 25% | None |
Mometasone Furoate 1mg/g 55 g in 1 BOTTLE, DROPPER |
1 |
Tier 1 |
25% | 25% | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
Monodox 100mg/1 250 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
Monodox 75mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
MONOKET 10MG TABLET |
3 |
Tier 3 |
25% | 25% | 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 |
1 |
Tier 1 |
25% | 25% | None |
MONTELUKAST SOD 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
montelukast sod 4 mg granules |
1 |
Tier 1 |
25% | 25% | None |
montelukast sod 4 mg tab chew |
1 |
Tier 1 |
25% | 25% | None |
montelukast sod 5 mg tab chew |
1 |
Tier 1 |
25% | 25% | None |
MONUROL PAK GRANULES 3 GM |
3 |
Tier 3 |
25% | 25% | None |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:200 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 100 MG CAP |
4 |
Tier 4 |
25% | 25% | S Q:60 /30Days |
MORPHINE SULFATE ER 20 MG CAP |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
MORPHINE SULFATE ER 50 MG CAP |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
MORPHINE SULFATE ER 80 MG CAP |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:700 /30Days |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:300 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
MORPHINE SULFATE TABLETS |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
MORPHINE SULFATE TABLETS |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOTOFEN TABLET |
3 |
Tier 3 |
25% | 25% | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
3 |
Tier 3 |
25% | 25% | None |
Moxatag 775mg/1 |
3 |
Tier 3 |
25% | 25% | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
MOZOBIL SOLUTION 24MG/1.2ML |
4 |
Tier 4 |
25% | 25% | P Q:10 /1Days |
MS Contin 100mg/1 |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days |
MS CONTIN 15MG TABLET 100 EA |
3 |
Tier 3 |
25% | 25% | Q:180 /30Days |
MS CONTIN 200MG TABLET SA |
3 |
Tier 3 |
25% | 25% | Q:180 /30Days |
MS Contin 30mg/1 |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days |
MS Contin 60mg/1 |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
mupirocin 2% cream |
1 |
Tier 1 |
25% | 25% | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
MUSTARGEN 10MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
MYAMBUTOL 400 MG 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/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
25% | 25% | P |
MYFORTIC 180MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
MYFORTIC 360MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYORISAN 10 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MYORISAN 20 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MYORISAN 40 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
MYOZYME 50MG VIAL |
4 |
Tier 4 |
25% | 25% | None |
MYRBETRIQ ER 25 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
MYRBETRIQ ER 50 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Mysoline 50mg/1 |
3 |
Tier 3 |
25% | 25% | None |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
3 |
Tier 3 |
25% | 25% | None |
MYTELASE 10MG CAPLET |
2 |
Tier 2 |
25% | 25% | None |