2016 Medicare Part D Plan Formulary Information |
Anthem MediBlue Essential (HMO) (H3655-032-0)
Benefit Details
|
The Anthem MediBlue Essential (HMO) (H3655-032-0) Formulary Drugs Starting with the Letter M in Lucas County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $0.00 Deductible: $60 |
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 |
$42.00 | $126.00 | None |
Magnesium sulfate 50% vial |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MALARONE 250-100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MALATHION 0.5% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MAPROTILINE 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:270 /30Days |
MAPROTILINE 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:135 /30Days |
MAPROTILINE 75MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MARLISSA-28 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MATULANE 50MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
MAVIK 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MAVIK 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MAXZIDE 37.5 MG-25 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MAXZIDE 50; 75mg 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MECLIZINE 12.5 MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
MECLIZINE 25 MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
MECLOFENAMATE 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MECLOFENAMATE 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $12.00 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $12.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MEGESTROL 20MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
MELOXICAM 15 MG TABLET |
1* |
Preferred Generic |
$4.00 | $12.00 | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET |
1* |
Preferred Generic |
$4.00 | $12.00 | Q:30 /30Days |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:300 /30Days |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /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 |
$42.00 | $126.00 | None |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENEST 2.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MENVEO INJECTION KIT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MERCAPTOPURINE 50MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Mesalamine 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Mesna 100 mg/ml vial |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
MESTINON 180MG TIMESPAN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MESTINON 60MG/5ML SYRUP |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METFORMIN HCL 1,000 MG TABLET |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:76 /30Days |
METFORMIN HCL 500MG TABLET (1000 CT) |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:153 /30Days |
METFORMIN HCL ER 1,000 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:75 /30Days |
METFORMIN HCL ER 500MG TABLET SR 24HR |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metformin Hydrochloride 750mg/1 |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:80 /30Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:90 /30Days |
METHADONE HCL 5MG TABLET (100 CT) |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /30Days |
Methadone Hydrochloride 10mg/5mL |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:900 /30Days |
Methadone Hydrochloride 5mg/5mL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:1800 /30Days |
METHAZOLAMIDE 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHAZOLAMIDE 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Methenamine Hippurate 1g/1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHIMAZOLE 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METHIMAZOLE 5MG TABLETS |
2* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methotrexate 1 gm vial |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHOTREXATE 2.5MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
Methotrexate 25 mg/ml vial |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
31% | N/A | P |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHYLPHENIDATE 10MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methylprednisolone 125 mg vial |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHYLPREDNISOLONE 16MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
methylprednisolone 40 mg vial |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
2* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOCLOPRAMIDE 5 MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2* |
Generic |
$15.00 | $45.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METOLAZONE 10MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METOLAZONE 2.5MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
METOLAZONE 5MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2* |
Generic |
$15.00 | $45.00 | None |
METOPROLOL SUCC ER 50 MG TAB |
2* |
Generic |
$15.00 | $45.00 | None |
METOPROLOL SUCCINATE ER 200 MG TAB |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
2* |
Generic |
$15.00 | $45.00 | None |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1* |
Preferred Generic |
$4.00 | $12.00 | None |
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1* |
Preferred Generic |
$4.00 | $12.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1* |
Preferred Generic |
$4.00 | $12.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
METRONIDAZOLE 0.75% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METRONIDAZOLE 0.75% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
metronidazole 375 mg capsule |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2* |
Generic |
$15.00 | $45.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2* |
Generic |
$15.00 | $45.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
METRONIDAZOLE VAGINAL GEL |
2* |
Generic |
$15.00 | $45.00 | None |
MEXILETINE 150MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MEXILETINE 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MEXILETINE 250MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MIACALCIN 200UNITS NASAL SPRA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:4 /30Days |
MIACALCIN 400 UNIT/2 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Micardis 20mg 3 BLISTER PACK per CARTON / 10 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
MICARDIS 40MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 | $285.00 | Q:60 /30Days |
MICARDIS HCT 40/12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
MICARDIS HCT 80/12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
MICARDIS HCT 80/25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
MICONAZOLE 3 200MG SUPPOS. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:6 /30Days |
MICROGESTIN 21 1-20 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MICROGESTIN 21 1.5-30 TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MICROGESTIN FE 1-20 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MICROGESTIN FE 1.5-30 TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MICROZIDE 12.5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MIDODRINE HCL 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 2.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Minipress 2mg/1 250 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MINOCYCLINE 50MG CAPSULE |
2* |
Generic |
$15.00 | $45.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
2* |
Generic |
$15.00 | $45.00 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MINOXIDIL 10MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
MINOXIDIL 2.5MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRAPEX 0.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MIRAPEX 0.75MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$15.00 | $45.00 | Q:90 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:45 /30Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$15.00 | $45.00 | Q:30 /30Days |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /30Days |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
2* |
Generic |
$15.00 | $45.00 | Q:45 /30Days |
misoprostol 100 mcg tablet |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
misoprostol 200 mcg tablet |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITOMYCIN 20 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Modafinil 100 mg tablet [Provigil] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
Modafinil 200 mg tablet [Provigil] |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
Moexipril hcl 15 mg tablet |
2* |
Generic |
$15.00 | $45.00 | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$15.00 | $45.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2* |
Generic |
$15.00 | $45.00 | None |
MOLINDONE HCL 10 MG TABLET [Moban] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOLINDONE HCL 25 MG TABLET [Moban] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOLINDONE HCL 5 MG TABLET [Moban] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOMETASONE FUROATE 0.1% CREAM |
2* |
Generic |
$15.00 | $45.00 | None |
MOMETASONE FUROATE 0.1% OINT |
2* |
Generic |
$15.00 | $45.00 | None |
MOMETASONE FUROATE 0.1% SOLN |
2* |
Generic |
$15.00 | $45.00 | None |
MOMETASONE FUROATE 50 MCG SPRY |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:17 /30Days |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
montelukast sod 4 mg granules [Singulair] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
montelukast sod 4 mg tab chew [Singulair] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
montelukast sod 5 mg tab chew [Singulair] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
Morphine 2 mg/ml isecure syr |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Morphine 4 mg/ml isecure syr |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days |
MORPHINE SULFATE 100MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:270 /30Days |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2700 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
MORPHINE SULFATE 15MG TABLETS |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:1350 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
MORPHINE SULFATE 30MG TABLETS |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:21 /2Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
mupirocin 2% cream |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MUPIROCIN 2% OINTMENT |
2* |
Generic |
$15.00 | $45.00 | None |
MUSTARGEN 10 MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
5 |
Specialty Tier |
31% | N/A | None |
MYCAMINE 50MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
31% | N/A | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
MYORISAN 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MYORISAN 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MYORISAN 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |