2015 Medicare Part D Plan Formulary Information |
WellCare Extra (PDP) (S5967-174-0)
Benefit Details
|
The WellCare Extra (PDP) (S5967-174-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 2 which includes: CT MA RI VT Plan Monthly Premium: $52.70 Deductible: $0 Qualifies for LIS: No |
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 |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Magnesium sulfate 50% vial |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Malathion 5mg/mL 1 BOTTLE per CARTON / 59 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MAPROTILINE 25MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MAPROTILINE 50MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MAPROTILINE 75MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MARLISSA-28 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MATULANE 50MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | 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 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEDROL 2 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | 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 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEGESTROL 20MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MELOXICAM 15 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | 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 |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MENEST 2.5MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
MENVEO INJECTION KIT |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Meprobamate 200mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | S |
Meprobamate 400mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | S |
MERCAPTOPURINE 50MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mesalamine 1 KIT per CARTON |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mesna 100 mg/ml vial |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
MESTINON 180MG TIMESPAN |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
MESTINON 60MG/5ML SYRUP |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Metadate er 20 mg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:90 /30Days |
METAPROTERENOL 10MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METAPROTERENOL 20MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:75 /30Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:150 /30Days |
METFORMIN HCL ER 1,000 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:60 /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 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:120 /30Days |
Metformin Hydrochloride 750mg/1 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:75 /30Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:240 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:240 /30Days |
Methadone Hydrochloride 10mg/5mL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methadone Hydrochloride 5mg/5mL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHAZOLAMIDE 25MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methenamine Hippurate 1g/1 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHIMAZOLE 10 MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHIMAZOLE 5MG TABLETS |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | S |
METHOCARBAMOL 750MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | S |
methotrexate 1 gm vial |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P |
METHOTREXATE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methotrexate 25 mg/ml vial |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
33% | N/A | P |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHYCLOTHIAZIDE 5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA 250MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHYLPHENIDATE 10MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:90 /30Days |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:2160 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:90 /30Days |
methylprednisolone 125 mg vial |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 32MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
methylprednisolone 40 mg vial |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METIPRANOLOL 0.3% EYE DROPS |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOLAZONE 10MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOLAZONE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOLAZONE 5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL SUCCINATE ER 200 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METRONIDAZOLE 0.75% LOTION |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
METRONIDAZOLE VAGINAL GEL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 150MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEXILETINE 200MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MEXILETINE 250MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIACALCIN 200IU/ML VIAL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
MICROGESTIN 21 1-20 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MICROGESTIN 21 1.5-30 TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MICROGESTIN FE 1-20 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MICROGESTIN FE 1.5-30 TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIDODRINE HCL 10MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Migergot suppository |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Millipred 5 mg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mimvey 1; 0.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 FILM COATED TABLETS in BLISTER PACK |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mimvey lo 0.5-0.1 mg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINITRAN 0.1 MG/HR PATCH |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINITRAN 0.2 MG/HR PATCH |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINITRAN 0.4 MG/HR PATCH |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINITRAN 0.6 MG/HR PATCH |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINOCYCLINE 50MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINOCYCLINE HCL 75MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINOXIDIL 10MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
misoprostol 100 mcg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
misoprostol 200 mcg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Modafinil 100 mg tablet [Provigil] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P Q:60 /30Days |
Modafinil 200 mg tablet [Provigil] |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
Moderiba 200 mg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Moexipril hcl 15 mg tablet |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MOMETASONE FUROATE 0.1% OINT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Mometasone Furoate 1mg/g |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
montelukast sod 5 mg tab chew [Singulair] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
MORPHINE 2 MG/ML ISECURE SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MORPHINE 4 MG/ML ISECURE SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MORPHINE 8 MG/ML ISECURE SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MORPHINE SULFATE 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MORPHINE SULFATE 15MG TABLETS |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MORPHINE SULFATE 30MG TABLETS |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:240 /30Days |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MOZOBIL 20 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:10 /1Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
mupirocin 2% cream |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MUPIROCIN 2% OINTMENT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
5 |
Specialty Tier |
33% | N/A | P |
MYCAMINE 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
33% | N/A | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P |
Mycophenolic Acid DR 180 mg tb |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P |
Mycophenolic Acid DR 360 mg tb |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | P |
MYORISAN 10 MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
MYORISAN 20 MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | 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 |
$7.00 | $17.50 | None |
MYOZYME 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |