2016 Medicare Part D Plan Formulary Information |
Security Blue HMO Standard (HMO) (H3957-003-0)
Benefit Details
|
The Security Blue HMO Standard (HMO) (H3957-003-0) Formulary Drugs Starting with the Letter M in Indiana County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $195.50 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 |
45% | 45% | None |
Magnesium sulfate 50% vial |
2 |
Generic |
$15.00 | $37.50 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
2 |
Generic |
$15.00 | $37.50 | None |
MAKENA 250 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
MALATHION 0.5% LOTION |
2 |
Generic |
$15.00 | $37.50 | None |
MAPROTILINE 25MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MAPROTILINE 50MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MAPROTILINE 75MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Marinol 10mg/1 60 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
45% | 45% | P |
MARINOL 2.5MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARINOL 5MG CAPSULE |
4 |
Non-Preferred Brand |
45% | 45% | P |
MARLISSA-28 TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MATULANE 50MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | None |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | None |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | None |
MAXALT 10mg/1 18 POUCH per CARTON / 1 TABLET in 1 POUCH |
4 |
Non-Preferred Brand |
45% | 45% | Q:12 /31Days |
MAXALT 5mg/1 18 POUCH per CARTON / 1 TABLET in 1 POUCH |
4 |
Non-Preferred Brand |
45% | 45% | Q:24 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT MLT 10 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:12 /31Days |
MAXALT MLT 5 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:24 /31Days |
MECLIZINE 12.5 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MECLIZINE 25 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MECLOFENAMATE 100MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MECLOFENAMATE 50MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROL 2 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEFENAMIC ACID 250 MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Generic |
$15.00 | $37.50 | None |
MEGACE ES 625MG/5ML SUSP |
4 |
Non-Preferred Brand |
45% | 45% | None |
MEGESTROL 20MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MEGESTROL 625 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $37.50 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Generic |
$15.00 | $37.50 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | 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 |
$3.00 | $7.50 | None |
MELOXICAM 7.5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
2 |
Generic |
$15.00 | $37.50 | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
4 |
Non-Preferred Brand |
45% | 45% | P |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
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 | $112.50 | None |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MENEST 2.5MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENHIBRIX VACCINE VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MENTAX 1% CREAM 15G TUBE |
4 |
Non-Preferred Brand |
45% | 45% | None |
MENVEO INJECTION KIT |
4 |
Non-Preferred Brand |
45% | 45% | None |
MEPRON 750MG/5ML ORAL SUSP |
5 |
Specialty Tier |
33% | N/A | None |
MERCAPTOPURINE 50MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
2 |
Generic |
$15.00 | $37.50 | None |
Mesalamine 1 KIT per CARTON |
2 |
Generic |
$15.00 | $37.50 | None |
Mesna 100 mg/ml vial |
2 |
Generic |
$15.00 | $37.50 | None |
MESNEX 400MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MESTINON 180MG TIMESPAN |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESTINON 60MG/5ML SYRUP |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Metadate er 20 mg tablet |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
METAPROTERENOL 10MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METAPROTERENOL 20MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $37.50 | None |
METAXALL 800 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Metaxalone 400 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METAXALONE 800 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METFORMIN HCL ER 1,000 MG TAB |
1 |
Preferred Generic |
$3.00 | $7.50 | 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 |
$3.00 | $7.50 | None |
Metformin Hydrochloride 750mg/1 |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METHADONE HCL 5MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $37.50 | P Q:248 /31Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | P Q:206 /31Days |
Methadone Hydrochloride 10mg/5mL |
2 |
Generic |
$15.00 | $37.50 | P Q:1033 /31Days |
Methadone Hydrochloride 5mg/5mL |
2 |
Generic |
$15.00 | $37.50 | P Q:2066 /31Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
2 |
Generic |
$15.00 | $37.50 | P Q:160 /30Days |
METHAMPHETAMINE HYDROCHLORIDE TABLETS 5 MG |
5 |
Specialty Tier |
33% | N/A | None |
METHAZOLAMIDE 25MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methenamine Hippurate 1g/1 |
2 |
Generic |
$15.00 | $37.50 | None |
METHIMAZOLE 10 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METHIMAZOLE 5MG TABLETS |
2 |
Generic |
$15.00 | $37.50 | None |
METHITEST 10MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
methotrexate 1 gm vial |
2 |
Generic |
$15.00 | $37.50 | P |
METHOTREXATE 2.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | P |
Methotrexate 25 mg/ml vial |
2 |
Generic |
$15.00 | $37.50 | P |
Methoxsalen 10 mg Capsule [8-MOP] |
2 |
Generic |
$15.00 | $37.50 | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
2 |
Generic |
$15.00 | $37.50 | None |
METHYCLOTHIAZIDE 5MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLIN 10 MG CHEWABLE |
4 |
Non-Preferred Brand |
45% | 45% | Q:186 /31Days |
METHYLIN 2.5 MG CHEWABLE TAB |
4 |
Non-Preferred Brand |
45% | 45% | Q:93 /31Days |
METHYLIN 5 MG CHEWABLE TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:93 /31Days |
METHYLPHENIDATE 10 MG CHEW TB |
2 |
Generic |
$15.00 | $37.50 | Q:186 /31Days |
METHYLPHENIDATE 10MG TABLET |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
METHYLPHENIDATE 2.5 MG CHEW TB |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
METHYLPHENIDATE 20MG TABLET |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
METHYLPHENIDATE 5 MG CHEW TB |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE CD 10 MG CAP |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPHENIDATE CD 30 MG CAP |
2 |
Generic |
$15.00 | $37.50 | None |
methylphenidate cd 50 mg cap |
2 |
Generic |
$15.00 | $37.50 | None |
methylphenidate cd 60 mg cap |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPHENIDATE ER 18 MG TAB |
2 |
Generic |
$15.00 | $37.50 | Q:31 /31Days |
METHYLPHENIDATE ER 27 MG TAB |
2 |
Generic |
$15.00 | $37.50 | Q:31 /31Days |
METHYLPHENIDATE ER 36 MG TAB |
2 |
Generic |
$15.00 | $37.50 | Q:31 /31Days |
METHYLPHENIDATE ER 40 MG CAP |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPHENIDATE ER 54 MG TAB |
2 |
Generic |
$15.00 | $37.50 | Q:31 /31Days |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | Q:31 /31Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | Q:93 /31Days |
METHYLPHENIDATE LA 20 MG CAP |
2 |
Generic |
$15.00 | $37.50 | None |
methylprednisolone 125 mg vial |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPREDNISOLONE 32MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
methylprednisolone 40 mg vial |
2 |
Generic |
$15.00 | $37.50 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$15.00 | $37.50 | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLTESTOSTERONE 10 MG CAP |
5 |
Specialty Tier |
33% | N/A | P |
METIPRANOLOL 0.3% EYE DROPS |
2 |
Generic |
$15.00 | $37.50 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
METOCLOPRAMIDE 5 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Generic |
$15.00 | $37.50 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
2 |
Generic |
$15.00 | $37.50 | None |
METOCLOPRAMIDE HCL ODT 10 MG |
2 |
Generic |
$15.00 | $37.50 | None |
METOCLOPRAMIDE HCL ODT 5 MG TB |
2 |
Generic |
$15.00 | $37.50 | None |
METOLAZONE 10MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 2.5MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METOLAZONE 5MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL SUCCINATE ER 200 MG TAB |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Generic |
$15.00 | $37.50 | None |
METRONIDAZOLE 0.75% LOTION |
2 |
Generic |
$15.00 | $37.50 | None |
metronidazole 375 mg capsule |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
2 |
Generic |
$15.00 | $37.50 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
metronidazole topical 1% gel |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE VAGINAL GEL |
2 |
Generic |
$15.00 | $37.50 | None |
MEXILETINE 150MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MEXILETINE 200MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MEXILETINE 250MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MIACALCIN 400 UNIT/2 ML VIAL |
4 |
Non-Preferred Brand |
45% | 45% | P |
MICONAZOLE 3 200MG SUPPOS. |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN 21 1-20 TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN 21 1.5-30 TAB |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN FE 1-20 TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN FE 1.5-30 TAB |
2 |
Generic |
$15.00 | $37.50 | None |
MIDODRINE HCL 10MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 2.5MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $37.50 | None |
Migergot suppository |
2 |
Generic |
$15.00 | $37.50 | None |
Miglitol 100 MG TABLET [Glyset] |
2 |
Generic |
$15.00 | $37.50 | None |
Miglitol 25 MG TABLET [Glyset] |
2 |
Generic |
$15.00 | $37.50 | None |
Miglitol 50 MG TABLET [Glyset] |
2 |
Generic |
$15.00 | $37.50 | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
4 |
Non-Preferred Brand |
45% | 45% | Q:8 /31Days |
MILLIPRED 10 MG/5 ML SOLUTION |
4 |
Non-Preferred Brand |
45% | 45% | None |
Millipred 5 mg tablet |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE 50MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE HCL 75MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | 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 |
Generic |
$15.00 | $37.50 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG |
2 |
Generic |
$15.00 | $37.50 | None |
MINOXIDIL 10MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MIRAPEX ER 0.375mg/1 1 BOTTLE, PLASTIC per CARTON / 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTI |
4 |
Non-Preferred Brand |
45% | 45% | None |
MIRAPEX ER 2.25mg/1 ER 30 TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRAPEX ER 3 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MIRAPEX ER 3.75mg/1 ER 30 TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MIRAPEX ER 4.5 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MIRCERA 100 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | P |
MIRCERA 200 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | P |
MIRCERA 50 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | P |
MIRCERA 75 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | P |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Generic |
$15.00 | $37.50 | None |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Generic |
$15.00 | $37.50 | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Generic |
$15.00 | $37.50 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Generic |
$15.00 | $37.50 | None |
misoprostol 100 mcg tablet |
2 |
Generic |
$15.00 | $37.50 | None |
misoprostol 200 mcg tablet |
2 |
Generic |
$15.00 | $37.50 | None |
MITIGARE 0.6 MG CAPSULE |
4 |
Non-Preferred Brand |
45% | 45% | Q:62 /31Days |
MITOMYCIN 20 MG VIAL |
2 |
Generic |
$15.00 | $37.50 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Generic |
$15.00 | $37.50 | None |
Modafinil 100 mg tablet [Provigil] |
2 |
Generic |
$15.00 | $37.50 | P Q:31 /31Days |
Modafinil 200 mg tablet [Provigil] |
2 |
Generic |
$15.00 | $37.50 | P Q:31 /31Days |
Moderiba 200 mg tablet |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Moderiba 400-400 mg dosepack |
2 |
Generic |
$15.00 | $37.50 | None |
Moderiba 600-600 mg dosepack |
2 |
Generic |
$15.00 | $37.50 | None |
Moexipril hcl 15 mg tablet |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
MOLINDONE HCL 10 MG TABLET [Moban] |
2 |
Generic |
$15.00 | $37.50 | None |
MOLINDONE HCL 25 MG TABLET [Moban] |
2 |
Generic |
$15.00 | $37.50 | None |
MOLINDONE HCL 5 MG TABLET [Moban] |
2 |
Generic |
$15.00 | $37.50 | None |
MOMETASONE FUROATE 0.1% CREAM |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOMETASONE FUROATE 0.1% OINT |
2 |
Generic |
$15.00 | $37.50 | None |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Generic |
$15.00 | $37.50 | None |
MOMETASONE FUROATE 50 MCG SPRY |
2 |
Generic |
$15.00 | $37.50 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Generic |
$15.00 | $37.50 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
montelukast sod 4 mg granules [Singulair] |
2 |
Generic |
$15.00 | $37.50 | None |
montelukast sod 4 mg tab chew [Singulair] |
2 |
Generic |
$15.00 | $37.50 | None |
montelukast sod 5 mg tab chew [Singulair] |
2 |
Generic |
$15.00 | $37.50 | None |
MONUROL 3 GM SACHET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MORPHINE 10 MG/ML ISECURE SYR |
4 |
Non-Preferred Brand |
45% | 45% | P Q:200 /30Days |
Morphine 2 mg/ml isecure syr |
2 |
Generic |
$15.00 | $37.50 | P Q:1000 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Morphine 4 mg/ml isecure syr |
2 |
Generic |
$15.00 | $37.50 | P Q:500 /30Days |
MORPHINE 8 MG/ML ISECURE SYR |
4 |
Non-Preferred Brand |
45% | 45% | P Q:250 /30Days |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $37.50 | P Q:310 /31Days |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
2 |
Generic |
$15.00 | $37.50 | P Q:2800 /31Days |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Generic |
$15.00 | $37.50 | P Q:100 /31Days |
MORPHINE SULFATE 15MG TABLETS |
2 |
Generic |
$15.00 | $37.50 | P Q:186 /31Days |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Generic |
$15.00 | $37.50 | P Q:31 /31Days |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
2 |
Generic |
$15.00 | $37.50 | P Q:1400 /31Days |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Generic |
$15.00 | $37.50 | P Q:100 /31Days |
MORPHINE SULFATE 30MG TABLETS |
2 |
Generic |
$15.00 | $37.50 | P Q:186 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 10 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 100 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 120 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:51 /31Days |
MORPHINE SULFATE ER 20 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 45 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 50 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 75 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 80 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE ER 90 MG CAP |
2 |
Generic |
$15.00 | $37.50 | P Q:62 /31Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Generic |
$15.00 | $37.50 | P Q:100 /31Days |
MOVANTIK 12.5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MOVANTIK 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Brand |
45% | 45% | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
45% | 45% | None |
MOXIFLOXACIN 400 MG/250 ML BAG [Avelox] |
4 |
Non-Preferred Brand |
45% | 45% | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MOZOBIL 20 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
MS Contin 100mg/1 |
4 |
Non-Preferred Brand |
45% | 45% | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MS CONTIN 15MG TABLET 100 EA |
4 |
Non-Preferred Brand |
45% | 45% | P Q:100 /31Days |
MS CONTIN 200MG TABLET SA |
4 |
Non-Preferred Brand |
45% | 45% | P Q:31 /31Days |
MS Contin 30mg/1 |
4 |
Non-Preferred Brand |
45% | 45% | P Q:100 /31Days |
MS Contin 60mg/1 |
4 |
Non-Preferred Brand |
45% | 45% | P Q:100 /31Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
45% | 45% | None |
mupirocin 2% cream |
2 |
Generic |
$15.00 | $37.50 | None |
MUPIROCIN 2% OINTMENT |
2 |
Generic |
$15.00 | $37.50 | None |
MUSTARGEN 10 MG VIAL |
4 |
Non-Preferred Brand |
45% | 45% | None |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
5 |
Specialty Tier |
33% | N/A | P |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
4 |
Non-Preferred Brand |
45% | 45% | None |
MYCAMINE 50MG VIAL |
4 |
Non-Preferred Brand |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLATE 200 MG/ML SUSP |
2 |
Generic |
$15.00 | $37.50 | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Generic |
$15.00 | $37.50 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Generic |
$15.00 | $37.50 | P |
Mycophenolic Acid DR 180 mg tb |
2 |
Generic |
$15.00 | $37.50 | P |
Mycophenolic Acid DR 360 mg tb |
2 |
Generic |
$15.00 | $37.50 | P |
MYFORTIC 180MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
MYFORTIC 360MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
MYORISAN 10 MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MYORISAN 20 MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
Myorisan 30 mg capsule |
2 |
Generic |
$15.00 | $37.50 | None |
MYORISAN 40 MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYRBETRIQ ER 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
MYRBETRIQ ER 50 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Mysoline 50mg/1 |
4 |
Non-Preferred Brand |
45% | 45% | None |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
4 |
Non-Preferred Brand |
45% | 45% | None |