2013 Medicare Part D Plan Formulary Information |
Gundersen Lutheran Senior Pref. Value (w/RX) (HMO) (H5262-003-0)
Benefit Details
|
The Gundersen Lutheran Senior Pref. Value (w/RX) (HMO) (H5262-003-0) Formulary Drugs Starting with the Letter M in MONROE County, WI: CMS MA Region 14 which includes: WI
|
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 |
$45.00 | N/A | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
MALARONE 62.5-25MG PED TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MAPROTILINE 25MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MAPROTILINE 50MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MAPROTILINE 75MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
MATULANE 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
MAXALT 10mg/1 18 POUCH in 1 CARTON / 1 TABLET in 1 POUCH |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:18 /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 |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:18 /30Days |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:18 /30Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:18 /30Days |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1* |
Preferred Generic |
$10.00 | N/A | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1* |
Preferred Generic |
$10.00 | N/A | None |
MECLOFENAMATE 100MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MECLOFENAMATE 50MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:1 /90Days |
Mefenamic Acid 250mg/1 30 CAPSULE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | S |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MEGACE ES 625MG/5ML SUSP |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
MEGESTROL 20MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Meloxicam 15mg/1 |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:300 /30Days |
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 |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.3MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MENEST 0.625MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MENEST 1.25MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MENEST 2.5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
MENVEO INJECTION KIT |
3 |
Preferred Brand |
$45.00 | N/A | None |
Meprobamate 200mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Meprobamate 400mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MEPRON 750MG/5ML ORAL SUSP |
3 |
Preferred Brand |
$45.00 | N/A | P |
MERCAPTOPURINE 50MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mesalamine 1 KIT in 1 CARTON |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
MESNEX 400MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
MESTINON 180MG TIMESPAN |
3 |
Preferred Brand |
$45.00 | N/A | None |
MESTINON 60MG/5ML SYRUP |
3 |
Preferred Brand |
$45.00 | N/A | None |
METADATE ER 20MG TABLET SA |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:90 /30Days |
METAPROTERENOL 10MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
METAPROTERENOL 20MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1* |
Preferred Generic |
$10.00 | N/A | Q:90 /30Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
1* |
Preferred Generic |
$10.00 | N/A | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1* |
Preferred Generic |
$10.00 | N/A | Q:120 /30Days |
Metformin Hydrochloride 750mg/1 |
1* |
Preferred Generic |
$10.00 | N/A | Q:90 /30Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | Q:90 /30Days |
METHADONE HCL 5MG TABLET (100 CT) |
1* |
Preferred Generic |
$10.00 | N/A | Q:90 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
Methadone Hydrochloride 10mg/5mL |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Methadone Hydrochloride 10mg/mL |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methadone Hydrochloride 5mg/5mL |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
METHADOSE 10MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
METHAZOLAMIDE 25MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHAZOLAMIDE 50MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methenamine Hippurate 1g/1 |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Methimazole 10mg/1 |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHIMAZOLE TABLETS |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHOTREXATE 2.5MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methotrexate 25mg/mL 10 VIAL in 1 BOX, UNIT-DOSE / 8 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
METHOTREXATE FOR INJECTION 1 GM/ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
METHYCLOTHIAZIDE 5MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA 250MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHYLDOPA 500MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHYLDOPATE 250MG/5ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
METHYLPHENIDATE 10MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:90 /30Days |
methylphenidate cd 50 mg cap |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
methylphenidate cd 60 mg cap |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
METHYLPHENIDATE ER 27 MG TAB |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE ER 36 MG TAB |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
METHYLPHENIDATE ER 54 MG TAB |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:90 /30Days |
METHYLPREDNISOLONE 16MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHYLPREDNISOLONE 32MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Methylprednisolone Sodium Succinate 1g/8mL 1 VIAL, SINGLE-DOSE in 1 BOX / 8 mL in 1 VIAL, SINGLE-DO |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1* |
Preferred Generic |
$10.00 | N/A | None |
METIPRANOLOL 0.3% EYE DROPS |
1* |
Preferred Generic |
$10.00 | N/A | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOCLOPRAMIDE 5 MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOLAZONE 10MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOLAZONE 2.5MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOLAZONE 5MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOPROLOL SUCC ER 100 MG TAB |
1* |
Preferred Generic |
$10.00 | N/A | Q:45 /30Days |
METOPROLOL SUCC ER 50 MG TAB |
1* |
Preferred Generic |
$10.00 | N/A | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1* |
Preferred Generic |
$10.00 | N/A | Q:60 /30Days |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
METROGEL TOPICAL 1% GEL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
METRONIDAZOLE 0.75% CREAM |
1* |
Preferred Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% LOTION |
1* |
Preferred Generic |
$10.00 | N/A | None |
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1* |
Preferred Generic |
$10.00 | N/A | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1* |
Preferred Generic |
$10.00 | N/A | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1* |
Preferred Generic |
$10.00 | N/A | None |
METRONIDAZOLE VAGINAL GEL |
1* |
Preferred Generic |
$10.00 | N/A | None |
MEXILETINE 150MG CAPSULE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MEXILETINE 200MG CAPSULE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MEXILETINE 250MG CAPSULE |
1* |
Preferred Generic |
$10.00 | N/A | None |
Micardis 20mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MICARDIS 40MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICARDIS 80MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MICARDIS HCT 40/12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MICARDIS HCT 80/12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MICARDIS HCT 80/25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MICONAZOLE 3 200MG SUPPOS. |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:3 /3Days |
MICROGESTIN 1-0.02MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MICROGESTIN 1.5-0.03MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MICROGESTIN FE 1.5/30 TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MICROGESTIN FE 1/20 TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MIDODRINE HCL 10MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MIDODRINE HCL 2.5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 5MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:16 /30Days |
MINOCYCLINE 100MG CAPSULE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MINOCYCLINE 50MG CAPSULE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MINOCYCLINE HCL 75MG CAPSULE |
1* |
Preferred Generic |
$10.00 | N/A | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1* |
Preferred Generic |
$10.00 | N/A | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MINOXIDIL 10MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
MINOXIDIL 2.5MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
MIRTAZAPINE 15 MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
Mirtazapine 7.5mg/1 |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1* |
Preferred Generic |
$10.00 | N/A | Q:30 /30Days |
misoprostol 200 mcg tablet |
1* |
Preferred Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
3 |
Preferred Brand |
$45.00 | N/A | P |
MODAFINIL 100 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
MODAFINIL 200 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
MOEXIPRIL HCL 15MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
MOEXIPRIL HCL 7.5MG TABLET |
1* |
Preferred Generic |
$10.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | None |
MOMETASONE FUROATE 0.1% SOLN |
1* |
Preferred Generic |
$10.00 | N/A | None |
Mometasone Furoate 1mg/g 45 g in 1 TUBE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1* |
Preferred Generic |
$10.00 | N/A | 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 |
3 |
Preferred Brand |
$45.00 | N/A | None |
MONTELUKAST SOD 10 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
montelukast sod 4 mg tab chew |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
montelukast sod 5 mg tab chew |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:30 /30Days |
MONUROL PAK GRANULES 3 GM |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
MORPHINE SULFATE 100MG TABLET SA |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1* |
Preferred Generic |
$10.00 | N/A | None |
MORPHINE SULFATE 15MG TABLET SA |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
MORPHINE SULFATE ER 100 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
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 |
$33.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE ER 50 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE ER 80 MG CAP |
2* |
Non-Preferred Generic |
$33.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE ORAL SOLUTION |
1* |
Preferred Generic |
$10.00 | N/A | None |
MORPHINE SULFATE ORAL SOLUTION |
1* |
Preferred Generic |
$10.00 | N/A | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
MORPHINE SULFATE TABLETS |
1* |
Preferred Generic |
$10.00 | N/A | Q:90 /30Days |
MORPHINE SULFATE TABLETS |
1* |
Preferred Generic |
$10.00 | N/A | Q:180 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUPIROCIN 2% OINTMENT |
1* |
Preferred Generic |
$10.00 | N/A | None |
MYCOBUTIN 150MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$33.00 | N/A | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2* |
Non-Preferred Generic |
$33.00 | N/A | P |
MYFORTIC 180MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
MYFORTIC 360MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
MYOZYME 50MG VIAL |
5 |
Specialty Tier |
30% | N/A | P |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:30 /30Days |
MYTELASE 10MG CAPLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |