2015 Medicare Part D Plan Formulary Information |
Touchstone Health Medicare Power (HMO) (H3327-001-0)
Benefit Details
|
The Touchstone Health Medicare Power (HMO) (H3327-001-0) Formulary Drugs Starting with the Letter M in BRONX County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $0.00 Deductible: $0 |
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 |
$80.00 | $200.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Malathion 5mg/mL 1 BOTTLE per CARTON / 59 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MAPROTILINE 25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
MATULANE 50MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
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 |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MECLOFENAMATE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MECLOFENAMATE 50MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | 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 |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:1 /90Days |
Mefenamic Acid 250mg/1 30 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MEGACE ES 625MG/5ML SUSP |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
MEGESTROL 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:120 /30Days |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
MELOXICAM 15 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /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 |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
MENEST 0.3MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MENEST 0.625MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MENEST 1.25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MENEST 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
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 |
$80.00 | $200.00 | None |
MENVEO INJECTION KIT |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
Meprobamate 200mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Meprobamate 400mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MERCAPTOPURINE 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Mesalamine 1 KIT per CARTON |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
MESTINON 180MG TIMESPAN |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
MESTINON 60MG/5ML SYRUP |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
METAPROTERENOL 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /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 |
$10.00 | $25.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
Metformin Hydrochloride 750mg/1 |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
METHADONE HCL 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
Methadone Hydrochloride 10mg/5mL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:600 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methadone Hydrochloride 5mg/5mL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:1200 /30Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P Q:120 /30Days |
METHAZOLAMIDE 25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Methenamine Hippurate 1g/1 |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHIMAZOLE 10 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHIMAZOLE 5MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
methotrexate 1 gm vial |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
METHOTREXATE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Methotrexate 25 mg/ml vial |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLDOPA 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLDOPATE 250MG/5ML VIAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHYLPHENIDATE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPHENIDATE 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE ER 18 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPHENIDATE ER 20 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
METHYLPHENIDATE ER 27 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPHENIDATE ER 30 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
METHYLPHENIDATE ER 36 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPHENIDATE ER 40 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
METHYLPHENIDATE ER 54 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
methylprednisolone 125 mg vial |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | 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 |
$10.00 | $25.00 | None |
methylprednisolone 40 mg vial |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | 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 |
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 |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
METOLAZONE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METOLAZONE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METOLAZONE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
METOPROLOL SUCCINATE ER 200 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
METOPROLOL SUCCINATE ER 25 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
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 |
$10.00 | $25.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METRONIDAZOLE 0.75% LOTION |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
METRONIDAZOLE VAGINAL GEL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | 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 |
$10.00 | $25.00 | None |
MEXILETINE 200MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MIACALCIN 200IU/ML VIAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
MICONAZOLE 3 200MG SUPPOS. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:3 /3Days |
MICROGESTIN 21 1-20 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MICROGESTIN 21 1.5-30 TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MICROGESTIN FE 1-20 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MICROGESTIN FE 1.5-30 TAB |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MIDODRINE HCL 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | 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 |
$10.00 | $25.00 | None |
Migergot suppository |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOCYCLINE 50MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOXIDIL 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
misoprostol 100 mcg tablet |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
misoprostol 200 mcg tablet |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Moexipril hcl 15 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MOMETASONE FUROATE 0.1% OINT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Mometasone Furoate 1mg/g |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
montelukast sod 4 mg granules [Singulair] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
montelukast sod 4 mg tab chew [Singulair] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
montelukast sod 5 mg tab chew [Singulair] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
MORPHINE SULFATE 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:180 /30Days |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:1800 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
MORPHINE SULFATE 15MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:900 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
MORPHINE SULFATE 30MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 10 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 100 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 120 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 20 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 45 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 50 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 75 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 80 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE ER 90 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:60 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
MOVANTIK 12.5 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days |
MOVANTIK 25 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:10 /10Days |
MOZOBIL 20 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:60 /30Days |
mupirocin 2% cream |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MUPIROCIN 2% OINTMENT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MUSTARGEN 10 MG VIAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLATE 200 MG/ML SUSP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Mycophenolic Acid DR 180 mg tb |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Mycophenolic Acid DR 360 mg tb |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
MYORISAN 10 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MYORISAN 20 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MYORISAN 40 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
MYOZYME 50MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |