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2014 Medicare Part D Plan Formulary Information
Humana Preferred Rx Plan (PDP) (S5884-134-0) Benefit Details
The Humana Preferred Rx Plan (PDP) (S5884-134-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 9 which includes: SC Plan Monthly Premium: $22.80 Deductible: $310 Qualifies for LIS: Yes
Drugs Starting with Letter M Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter M Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML	4	Non-Preferred Brand	35%	35%	None
MAGNESIUM SULFATE INJECTION 5 GM/10ML	2	Non-Preferred Generic	$2.00	$0.00	None
Malathion 5mg/mL 1 BOTTLE per CARTON / 59 mL in 1 BOTTLE	3	Preferred Brand	20%	20%	None
MAPROTILINE 25MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MAPROTILINE 50MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MAPROTILINE 75MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MARLISSA-28 TABLET	4	Non-Preferred Brand	35%	35%	None
MARPLAN 10MG TABLET (100 CT)	4	Non-Preferred Brand	35%	35%	None
MATULANE 50MG CAPSULE	5	Specialty Tier	25%	N/A	None
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT	2	Non-Preferred Generic	$2.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT	2	Non-Preferred Generic	$2.00	$0.00	None
MECLOFENAMATE 100MG CAPSULE	3	Preferred Brand	20%	20%	None
MECLOFENAMATE 50MG CAPSULE	3	Preferred Brand	20%	20%	None
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE	1	Preferred Generic	$1.00	$0.00	None
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE	1	Preferred Generic	$1.00	$0.00	None
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE	1	Preferred Generic	$1.00	$0.00	None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN	2	Non-Preferred Generic	$2.00	$0.00	Q:1 /90Days
MEFLOQUINE HCL 250MG TABLET 25 BOT	2	Non-Preferred Generic	$2.00	$0.00	None
MEGESTROL 20MG TABLET	1	Preferred Generic	$1.00	$0.00	P
MEGESTROL ACETATE 40MG TABLET (250 CT)	3	Preferred Brand	20%	20%	P
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC	3	Preferred Brand	20%	20%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MEKINIST 0.5 MG TABLET	5	Specialty Tier	25%	N/A	P Q:120 /30Days
MEKINIST 2 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
MELOXICAM 15 MG TABLET	1	Preferred Generic	$1.00	$0.00	Q:30 /30Days
MELOXICAM 7.5 MG TABLET	1	Preferred Generic	$1.00	$0.00	Q:60 /30Days
MELOXICAM 7.5MG/5ML SUSPENSION ORAL	2	Non-Preferred Generic	$2.00	$0.00	Q:300 /30Days
MELPHALAN 5 MG/ML INJECTABLE SOLUTION	2	Non-Preferred Generic	$2.00	$0.00	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	4	Non-Preferred Brand	35%	35%	None
MENEST 0.3MG TABLET	4	Non-Preferred Brand	35%	35%	P
MENEST 0.625MG TABLET	4	Non-Preferred Brand	35%	35%	P
MENEST 1.25MG TABLET	4	Non-Preferred Brand	35%	35%	P
MENEST 2.5MG TABLET	4	Non-Preferred Brand	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MENOMUNE-A/C/Y/W-135 VIAL	4	Non-Preferred Brand	35%	35%	None
MENTAX 1% CREAM 15G TUBE	4	Non-Preferred Brand	35%	35%	None
MENVEO INJECTION KIT	4	Non-Preferred Brand	35%	35%	None
MEPRON 750MG/5ML ORAL SUSP	5	Specialty Tier	25%	N/A	None
MERCAPTOPURINE 50MG TABLET	3	Preferred Brand	20%	20%	None
MEROPENEM 500MG/VIAL FOR INJECTION	4	Non-Preferred Brand	35%	35%	None
MERREM INJECTION 500MG 10X20MLVIALS VIAL	4	Non-Preferred Brand	35%	35%	None
Mesalamine 1 KIT per CARTON	4	Non-Preferred Brand	35%	35%	None
MESNA 100 MG/ML VIAL	4	Non-Preferred Brand	35%	35%	None
MESNEX 100MG/ML INJECTION	4	Non-Preferred Brand	35%	35%	None
MESNEX 400MG TABLET	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METADATE CD 10MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METADATE CD 20MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
Metadate CD 30mg EXTENDED RELEASE 100 CAPSULE BOTTLE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
METADATE CD 40MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METADATE CD 50MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METADATE CD 60MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METAPROTERENOL 10MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
METAPROTERENOL 20MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC	3	Preferred Brand	20%	20%	None
METFORMIN HCL 1000MG TABLET (500 CT)	1	Preferred Generic	$1.00	$0.00	None
METFORMIN HCL 500MG TABLET (1000 CT)	1	Preferred Generic	$1.00	$0.00	None
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	$1.00	$0.00	Q:120 /30Days
Metformin Hydrochloride 750mg/1	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE	1	Preferred Generic	$1.00	$0.00	None
METHADONE HCL 5MG TABLET (100 CT)	4	Non-Preferred Brand	35%	35%	Q:480 /30Days
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	Q:240 /30Days
Methadone Hydrochloride 10mg/5mL	4	Non-Preferred Brand	35%	35%	Q:1800 /30Days
Methadone Hydrochloride 5mg/5mL	4	Non-Preferred Brand	35%	35%	Q:3600 /30Days
METHADONE HYDROCHLORIDE INJECTION 10MG/ML	4	Non-Preferred Brand	35%	35%	Q:360 /30Days
METHAMPHETAMINE HYDROCHLORIDE TABLETS 5 MG	4	Non-Preferred Brand	35%	35%	Q:150 /30Days
METHAZOLAMIDE 25MG TABLET	4	Non-Preferred Brand	35%	35%	None
METHAZOLAMIDE 50MG TABLET	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Methenamine Hippurate 1g/1	4	Non-Preferred Brand	35%	35%	None
METHIMAZOLE 10 MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
METHIMAZOLE 5MG TABLETS	2	Non-Preferred Generic	$2.00	$0.00	None
METHITEST 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
Methocarbamol 500mg 100 TABLET BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	P
METHOCARBAMOL 750MG TABLET (500 CT)	2	Non-Preferred Generic	$2.00	$0.00	P
methotrexate 1 gm vial	2	Non-Preferred Generic	$2.00	$0.00	None
METHOTREXATE 2.5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
methotrexate 25 mg/ml vial	2	Non-Preferred Generic	$2.00	$0.00	None
METHSCOPOLAMINE BROMIDE 2.5MG TABLET	3	Preferred Brand	20%	20%	None
METHSCOPOLAMINE BROMIDE 5 MG TAB	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHYCLOTHIAZIDE 5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE	3	Preferred Brand	20%	20%	None
METHYLIN 10 MG CHEWABLE	4	Non-Preferred Brand	35%	35%	Q:180 /30Days
METHYLIN 2.5 MG CHEWABLE TAB	4	Non-Preferred Brand	35%	35%	Q:150 /30Days
METHYLIN 5 MG CHEWABLE TABLET	4	Non-Preferred Brand	35%	35%	Q:150 /30Days
METHYLPHENIDATE 10MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	Q:90 /30Days
METHYLPHENIDATE 20MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	Q:90 /30Days
METHYLPHENIDATE ER 18 MG TAB	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METHYLPHENIDATE ER 20 MG CAP	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METHYLPHENIDATE ER 27 MG TAB	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METHYLPHENIDATE ER 30 MG CAP	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHYLPHENIDATE ER 36 MG TAB	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
METHYLPHENIDATE ER 40 MG CAP	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
METHYLPHENIDATE ER 54 MG TAB	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE	4	Non-Preferred Brand	35%	35%	Q:900 /30Days
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	Q:90 /30Days
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE	4	Non-Preferred Brand	35%	35%	Q:1800 /30Days
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	Q:90 /30Days
methylprednisolone 125 mg vial	2	Non-Preferred Generic	$2.00	$0.00	None
METHYLPREDNISOLONE 16MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
METHYLPREDNISOLONE 32MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
methylprednisolone 40 mg vial	2	Non-Preferred Generic	$2.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Non-Preferred Generic	$2.00	$0.00	None
Methylprednisolone 4mg/1 100 TABLET BOTTLE	1	Preferred Generic	$1.00	$0.00	P
METHYLPREDNISOLONE 8 MG ORAL TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS	2	Non-Preferred Generic	$2.00	$0.00	None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM	1	Preferred Generic	$1.00	$0.00	P
METIPRANOLOL 0.3% EYE DROPS	2	Non-Preferred Generic	$2.00	$0.00	None
Metoclopramide 10mg/1 500 TABLET BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	None
METOCLOPRAMIDE 5 MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL	2	Non-Preferred Generic	$2.00	$0.00	None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT	2	Non-Preferred Generic	$2.00	$0.00	None
METOLAZONE 10MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METOLAZONE 2.5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
METOLAZONE 5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
METOPROLOL SUCC ER 100 MG TAB	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
METOPROLOL SUCC ER 50 MG TAB	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
METOPROLOL SUCCINATE ER 200 MG TAB	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
METOPROLOL SUCCINATE ER 25 MG TAB	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
METOPROLOL TARTRATE 25MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	None
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD	2	Non-Preferred Generic	$2.00	$0.00	None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)	1	Preferred Generic	$1.00	$0.00	None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)	1	Preferred Generic	$1.00	$0.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET	3	Preferred Brand	20%	20%	None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET	3	Preferred Brand	20%	20%	None
METRONIDAZOLE 0.75% CREAM	3	Preferred Brand	20%	20%	None
METRONIDAZOLE 0.75% LOTION	3	Preferred Brand	20%	20%	None
metronidazole 375 mg capsule	2	Non-Preferred Generic	$2.00	$0.00	None
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL	2	Non-Preferred Generic	$2.00	$0.00	None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL	2	Non-Preferred Generic	$2.00	$0.00	None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE	3	Preferred Brand	20%	20%	None
METRONIDAZOLE VAGINAL GEL	2	Non-Preferred Generic	$2.00	$0.00	None
MEXILETINE 150MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
MEXILETINE 200MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MEXILETINE 250MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
MICONAZOLE 3 200MG SUPPOS.	2	Non-Preferred Generic	$2.00	$0.00	None
MICROGESTIN 1-0.02MG TABLET	4	Non-Preferred Brand	35%	35%	None
MICROGESTIN 1.5-0.03MG TABLET	4	Non-Preferred Brand	35%	35%	None
MICROGESTIN FE 1.5/30 TABLET	4	Non-Preferred Brand	35%	35%	None
MICROGESTIN FE 1/20 TABLET	4	Non-Preferred Brand	35%	35%	None
MIDODRINE HCL 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
MIDODRINE HCL 2.5MG TABLET	4	Non-Preferred Brand	35%	35%	None
MIDODRINE HCL 5MG TABLET (100 CT)	4	Non-Preferred Brand	35%	35%	None
MIGERGOT 2-100MG SUPPOSITORY RECTAL	4	Non-Preferred Brand	35%	35%	None
MINOCYCLINE 100 MG CAPSULE	2	Non-Preferred Generic	$2.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MINOCYCLINE 50MG CAPSULE	2	Non-Preferred Generic	$2.00	$0.00	None
MINOCYCLINE HCL 75MG CAPSULE	2	Non-Preferred Generic	$2.00	$0.00	None
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	None
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG	2	Non-Preferred Generic	$2.00	$0.00	None
MINOXIDIL 10MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MINOXIDIL 2.5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MIRTAZAPINE 15 MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Mirtazapine 7.5mg/1	2	Non-Preferred Generic	$2.00	$0.00	None
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
MIRTAZAPINE TABLET 30MG (30 CT)	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
misoprostol 100 mcg tablet	3	Preferred Brand	20%	20%	None
misoprostol 200 mcg tablet	3	Preferred Brand	20%	20%	None
MITOMYCIN 20 MG VIAL	4	Non-Preferred Brand	35%	35%	None
MITOXANTRONE INJECTION 2MG 125ML VIAL	3	Preferred Brand	20%	20%	None
MODAFINIL 100 MG TABLET [Provigil]	4	Non-Preferred Brand	35%	35%	P Q:60 /30Days
MOEXIPRIL HCL 15 MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
MOMETASONE FUROATE 0.1% OINT	2	Non-Preferred Generic	$2.00	$0.00	None
MOMETASONE FUROATE 0.1% SOLN	2	Non-Preferred Generic	$2.00	$0.00	None
Mometasone Furoate 1mg/g 45 g in 1 TUBE	2	Non-Preferred Generic	$2.00	$0.00	None
MONTELUKAST SOD 10 MG TABLET [Singulair]	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
montelukast sod 4 mg granules [Singulair]	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
montelukast sod 4 mg tab chew [Singulair]	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
montelukast sod 5 mg tab chew [Singulair]	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
Morphine 2 mg/ml isecure syr	3	Preferred Brand	20%	20%	Q:1800 /30Days
Morphine 4 mg/ml isecure syr	3	Preferred Brand	20%	20%	Q:900 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MORPHINE SULFATE 100MG TABLET SA	3	Preferred Brand	20%	20%	Q:180 /30Days
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE	3	Preferred Brand	20%	20%	Q:600 /30Days
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION	3	Preferred Brand	20%	20%	Q:2700 /30Days
MORPHINE SULFATE 15MG TABLET SA	3	Preferred Brand	20%	20%	Q:120 /30Days
MORPHINE SULFATE 15MG TABLETS	3	Preferred Brand	20%	20%	Q:180 /30Days
MORPHINE SULFATE 200MG TABLET SA	3	Preferred Brand	20%	20%	Q:90 /30Days
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION	3	Preferred Brand	20%	20%	Q:1350 /30Days
MORPHINE SULFATE 30MG TABLET SA	3	Preferred Brand	20%	20%	Q:120 /30Days
MORPHINE SULFATE 30MG TABLETS	3	Preferred Brand	20%	20%	Q:180 /30Days
MORPHINE SULFATE TABLET ER 60MG (100 CT)	3	Preferred Brand	20%	20%	Q:120 /30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE	4	Non-Preferred Brand	35%	35%	None
MOZOBIL 20 MG/ML VIAL	5	Specialty Tier	25%	N/A	P Q:8 /30Days
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
mupirocin 2% cream	4	Non-Preferred Brand	35%	35%	None
MUPIROCIN 2% OINTMENT	2	Non-Preferred Generic	$2.00	$0.00	None
MUSTARGEN 10 MG VIAL	4	Non-Preferred Brand	35%	35%	None
MYALEPT 11.3 MG (5 MG/ML) VIAL	5	Specialty Tier	25%	N/A	P Q:30 /30Days
MYCOBUTIN 150MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK	3	Preferred Brand	20%	20%	P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT	3	Preferred Brand	20%	20%	P
Mycophenolic Acid DR 180 mg tb	3	Preferred Brand	20%	20%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Mycophenolic Acid DR 360 mg tb	3	Preferred Brand	20%	20%	P
MYFORTIC 180MG TABLET	3	Preferred Brand	20%	20%	P
MYFORTIC 360MG TABLET	3	Preferred Brand	20%	20%	P
MYOZYME 50MG VIAL	5	Specialty Tier	25%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Humana Preferred Rx Plan (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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.