2013 Medicare Part D Plan Formulary Information |
SeniorCare Sr MedOption - Basic Rx (Cost) (H4564-021-0)
Benefit Details
|
The SeniorCare Sr MedOption - Basic Rx (Cost) (H4564-021-0) Formulary Drugs Starting with the Letter M in ANDERSON County, TX: CMS MA Region 17 which includes: TX
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Drugs Starting with Letter M
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MALARONE 250-100MG TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MALARONE 62.5-25MG PED TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MAPROTILINE 25MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MAPROTILINE 50MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MAPROTILINE 75MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MARLISSA-28 TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MARPLAN 10MG TABLET (100 CT) |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MATULANE 50MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
MAXALT 10mg/1 18 POUCH in 1 CARTON / 1 TABLET in 1 POUCH |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT 5mg/1 18 POUCH in 1 CARTON / 1 TABLET in 1 POUCH |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | Q:24 /30Days |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | Q:12 /30Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | Q:24 /30Days |
MECLOFENAMATE 100MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEGESTROL 20MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$7.00 | $14.00 | P |
Meloxicam 15mg/1 |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MELOXICAM 7.5 MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
1 |
Preferred Generic |
$7.00 | $14.00 | 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 |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MENEST 0.3MG TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MENEST 0.625MG TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MENEST 1.25MG TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MENEST 2.5MG TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENVEO INJECTION KIT |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
Meprobamate 200mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Meprobamate 400mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEPRON 750MG/5ML ORAL SUSP |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Mesalamine 1 KIT in 1 CARTON |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MESNEX 400MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METFORMIN HCL ER 1,000 MG TAB |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metformin Hydrochloride 750mg/1 |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:240 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:240 /30Days |
Methadone Hydrochloride 10mg/5mL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methadone Hydrochloride 10mg/mL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methadone Hydrochloride 5mg/5mL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methenamine Hippurate 1g/1 |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methimazole 10mg/1 |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHIMAZOLE TABLETS |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methotrexate 25mg/mL 10 VIAL in 1 BOX, UNIT-DOSE / 8 mL in 1 VIAL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLDOPA 250MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLDOPA 500MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLIN 10 MG CHEWABLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLIN 2.5 MG CHEWABLE TAB |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLIN 5 MG CHEWABLE TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE 20MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE CD 10 MG CAP |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE ER 20 MG CAP |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE ER 30 MG CAP |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE ER 40 MG CAP |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
methylprednisolone 125 mg vial |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
methylprednisolone 40 mg vial |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS |
1 |
Preferred Generic |
$7.00 | $14.00 | 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 |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOLAZONE 10MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOLAZONE 2.5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOLAZONE 5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METROGEL TOPICAL 1% GEL |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% CREAM |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
METRONIDAZOLE VAGINAL GEL |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEXILETINE 150MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEXILETINE 200MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MEXILETINE 250MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN 1-0.02MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MICROGESTIN FE 1/20 TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MIDODRINE HCL 10MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
MIDODRINE HCL 2.5MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:8 /30Days |
MILLIPRED TABLETS 5MG |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MINOXIDIL 10MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MINOXIDIL 2.5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MIRTAZAPINE 15 MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Mirtazapine 7.5mg/1 |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
misoprostol 100 mcg tablet |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
misoprostol 200 mcg tablet |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Preferred Generic |
$7.00 | $14.00 | P |
MODAFINIL 100 MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MODAFINIL 200 MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MOMETASONE FUROATE 0.1% SOLN |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Mometasone Furoate 1mg/g 45 g in 1 TUBE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MONTELUKAST SOD 10 MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
montelukast sod 4 mg granules |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
montelukast sod 4 mg tab chew |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
montelukast sod 5 mg tab chew |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MONUROL PAK GRANULES 3 GM |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:120 /30Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:180 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:120 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:180 /30Days |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | Q:120 /30Days |
MORPHINE SULFATE TABLETS |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MORPHINE SULFATE TABLETS |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MOZOBIL SOLUTION 24MG/1.2ML |
4 |
Specialty Tier |
33% | 33% | P Q:10 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
mupirocin 2% cream |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MUPIROCIN 2% OINTMENT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
MYCOBUTIN 150MG CAPSULE |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
1 |
Preferred Generic |
$7.00 | $14.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | P |
MYFORTIC 180MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYFORTIC 360MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | P |
MYRBETRIQ ER 25 MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |
MYRBETRIQ ER 50 MG TABLET |
3 |
Non-Preferred Brand |
$64.00 | $128.00 | None |