2016 Medicare Part D Plan Formulary Information |
Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0)
Benefit Details
|
The Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0) Formulary Drugs Starting with the Letter M in Bayamon County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $360 |
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* |
Non-Preferred Brand |
25% | 25% | None |
Magnesium sulfate 50% vial |
2 |
Preferred Brand |
25% | 25% | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
Generic |
25% | 25% | None |
MALATHION 0.5% LOTION |
3* |
Non-Preferred Brand |
25% | 25% | None |
MAPROTILINE 25MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MAPROTILINE 50MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MAPROTILINE 75MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MARLISSA-28 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MARPLAN 10MG TABLET (100 CT) |
3* |
Non-Preferred Brand |
25% | 25% | None |
MATULANE 50MG CAPSULE |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
3* |
Non-Preferred Brand |
25% | 25% | None |
MECLIZINE 12.5 MG TABLET |
1 |
Generic |
25% | 25% | None |
MECLIZINE 25 MG TABLET |
1 |
Generic |
25% | 25% | None |
MECLOFENAMATE 100MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
MECLOFENAMATE 50MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
MEDROL 2 MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Generic |
25% | 25% | Q:1 /90Days |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL 20MG TABLET |
1 |
Generic |
25% | 25% | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Generic |
25% | 25% | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
MEKINIST 0.5 MG TABLET |
4* |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
MEKINIST 2 MG TABLET |
4* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
MELOXICAM 15 MG TABLET |
1 |
Generic |
25% | 25% | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET |
1 |
Generic |
25% | 25% | Q:60 /30Days |
MELOXICAM 7.5MG/5ML SUSPENSION ORAL |
3* |
Non-Preferred Brand |
25% | 25% | Q:300 /30Days |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
1 |
Generic |
25% | 25% | P |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
2 |
Preferred Brand |
25% | 25% | P Q:98 /30Days |
MEMANTINE HCL 10 MG TABLET [Namenda] |
2 |
Preferred Brand |
25% | 25% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Preferred Brand |
25% | 25% | P Q:360 /30Days |
MEMANTINE HCL 5 MG TABLET [Namenda] |
2 |
Preferred Brand |
25% | 25% | P Q:60 /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* |
Non-Preferred Brand |
25% | 25% | None |
MENEST 0.3MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MENEST 0.625MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MENEST 1.25MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MENEST 2.5MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MENHIBRIX VACCINE VIAL |
3* |
Non-Preferred Brand |
25% | 25% | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3* |
Non-Preferred Brand |
25% | 25% | None |
MENOSTAR 14 MCG/DAY PATCH |
3* |
Non-Preferred Brand |
25% | 25% | Q:8 /28Days |
MENTAX 1% CREAM 15G TUBE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENVEO INJECTION KIT |
3* |
Non-Preferred Brand |
25% | 25% | None |
MEPERIDINE 50MG/5ML SYRUP |
2 |
Preferred Brand |
25% | 25% | Q:720 /30Days |
Meperidine Hydrochloride 100mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
25% | 25% | Q:360 /30Days |
Meperidine Hydrochloride 50mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
25% | 25% | Q:480 /30Days |
MERCAPTOPURINE 50MG TABLET |
1 |
Generic |
25% | 25% | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
3* |
Non-Preferred Brand |
25% | 25% | None |
Mesalamine 1 KIT per CARTON |
3* |
Non-Preferred Brand |
25% | 25% | None |
Mesna 100 mg/ml vial |
3* |
Non-Preferred Brand |
25% | 25% | P |
MESNEX 400MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MESTINON 180MG TIMESPAN |
2 |
Preferred Brand |
25% | 25% | None |
MESTINON 60MG/5ML SYRUP |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 10MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
METAPROTERENOL 20MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
3* |
Non-Preferred Brand |
25% | 25% | None |
Metaxalone 400 MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
METAXALONE 800 MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
Generic |
25% | 25% | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Generic |
25% | 25% | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Generic |
25% | 25% | Q:120 /30Days |
Metformin Hydrochloride 750mg/1 |
1 |
Generic |
25% | 25% | Q:60 /30Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
METHADONE HCL 5MG TABLET (100 CT) |
2 |
Preferred Brand |
25% | 25% | Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
25% | 25% | Q:240 /30Days |
Methadone Hydrochloride 10mg/5mL |
2 |
Preferred Brand |
25% | 25% | Q:1800 /30Days |
Methadone Hydrochloride 5mg/5mL |
2 |
Preferred Brand |
25% | 25% | Q:3600 /30Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
2 |
Preferred Brand |
25% | 25% | Q:360 /30Days |
METHAZOLAMIDE 25MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
METHAZOLAMIDE 50MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
Methenamine Hippurate 1g/1 |
3* |
Non-Preferred Brand |
25% | 25% | None |
METHIMAZOLE 10 MG TABLET |
1 |
Generic |
25% | 25% | None |
METHIMAZOLE 5MG TABLETS |
1 |
Generic |
25% | 25% | None |
METHITEST 10MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOCARBAMOL 750MG TABLET (500 CT) |
3* |
Non-Preferred Brand |
25% | 25% | None |
methotrexate 1 gm vial |
1 |
Generic |
25% | 25% | None |
METHOTREXATE 2.5MG TABLET |
1 |
Generic |
25% | 25% | P |
Methotrexate 25 mg/ml vial |
1 |
Generic |
25% | 25% | None |
Methoxsalen 10 mg Capsule [8-MOP] |
2 |
Preferred Brand |
25% | 25% | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
3* |
Non-Preferred Brand |
25% | 25% | None |
METHYCLOTHIAZIDE 5MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
METHYLDOPA 250MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
25% | 25% | None |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA/HCTZ 250-15 TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
2 |
Preferred Brand |
25% | 25% | None |
METHYLIN 10 MG CHEWABLE |
3* |
Non-Preferred Brand |
25% | 25% | Q:180 /30Days |
METHYLIN 2.5 MG CHEWABLE TAB |
3* |
Non-Preferred Brand |
25% | 25% | Q:150 /30Days |
METHYLIN 5 MG CHEWABLE TABLET |
3* |
Non-Preferred Brand |
25% | 25% | Q:150 /30Days |
METHYLPHENIDATE 10 MG CHEW TB |
3* |
Non-Preferred Brand |
25% | 25% | Q:180 /30Days |
METHYLPHENIDATE 10MG TABLET |
1 |
Generic |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE 2.5 MG CHEW TB |
3* |
Non-Preferred Brand |
25% | 25% | Q:150 /30Days |
METHYLPHENIDATE 20MG TABLET |
1 |
Generic |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE 5 MG CHEW TB |
3* |
Non-Preferred Brand |
25% | 25% | Q:150 /30Days |
METHYLPHENIDATE CD 10 MG CAP |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE CD 30 MG CAP |
1 |
Generic |
25% | 25% | Q:60 /30Days |
methylphenidate cd 50 mg cap |
1 |
Generic |
25% | 25% | Q:30 /30Days |
methylphenidate cd 60 mg cap |
1 |
Generic |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 18 MG TAB |
1 |
Generic |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 27 MG TAB |
1 |
Generic |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 36 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
METHYLPHENIDATE ER 40 MG CAP |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
METHYLPHENIDATE ER 54 MG TAB |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
3* |
Non-Preferred Brand |
25% | 25% | Q:900 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | Q:90 /30Days |
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE |
3* |
Non-Preferred Brand |
25% | 25% | Q:1800 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | Q:180 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE LA 20 MG CAP |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
methylprednisolone 125 mg vial |
3* |
Non-Preferred Brand |
25% | 25% | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Generic |
25% | 25% | P |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Generic |
25% | 25% | P |
methylprednisolone 40 mg vial |
3* |
Non-Preferred Brand |
25% | 25% | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Generic |
25% | 25% | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | P |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Generic |
25% | 25% | P |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Generic |
25% | 25% | P |
METHYLTESTOSTERONE 10 MG CAP |
2 |
Preferred Brand |
25% | 25% | None |
METIPRANOLOL 0.3% EYE DROPS |
2 |
Preferred Brand |
25% | 25% | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Generic |
25% | 25% | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
1 |
Generic |
25% | 25% | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
Generic |
25% | 25% | None |
METOLAZONE 10MG TABLET |
1 |
Generic |
25% | 25% | None |
METOLAZONE 2.5MG TABLET |
1 |
Generic |
25% | 25% | None |
METOLAZONE 5MG TABLET |
1 |
Generic |
25% | 25% | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
METOPROLOL SUCCINATE ER 200 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
METOPROLOL SUCCINATE ER 25 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
1 |
Generic |
25% | 25% | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Generic |
25% | 25% | None |
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT |
1 |
Generic |
25% | 25% | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Generic |
25% | 25% | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Generic |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Generic |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Generic |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% CREAM |
1 |
Generic |
25% | 25% | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Generic |
25% | 25% | None |
metronidazole 375 mg capsule |
1 |
Generic |
25% | 25% | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
3* |
Non-Preferred Brand |
25% | 25% | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Generic |
25% | 25% | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Generic |
25% | 25% | None |
metronidazole topical 1% gel |
3* |
Non-Preferred Brand |
25% | 25% | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Generic |
25% | 25% | None |
METRONIDAZOLE VAGINAL GEL |
1 |
Generic |
25% | 25% | None |
MEXILETINE 150MG CAPSULE |
1 |
Generic |
25% | 25% | None |
MEXILETINE 200MG CAPSULE |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 250MG CAPSULE |
1 |
Generic |
25% | 25% | None |
MIACALCIN 400 UNIT/2 ML VIAL |
3* |
Non-Preferred Brand |
25% | 25% | None |
MICONAZOLE 3 200MG SUPPOS. |
2 |
Preferred Brand |
25% | 25% | None |
MICROGESTIN 21 1-20 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MICROGESTIN 21 1.5-30 TAB |
3* |
Non-Preferred Brand |
25% | 25% | None |
MICROGESTIN FE 1-20 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MICROGESTIN FE 1.5-30 TAB |
3* |
Non-Preferred Brand |
25% | 25% | None |
MIDODRINE HCL 10MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Preferred Brand |
25% | 25% | None |
Miglitol 100 MG TABLET [Glyset] |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Miglitol 25 MG TABLET [Glyset] |
3* |
Non-Preferred Brand |
25% | 25% | None |
Miglitol 50 MG TABLET [Glyset] |
3* |
Non-Preferred Brand |
25% | 25% | None |
Mimvey 1; 0.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 FILM COATED TABLETS in BLISTER PACK |
1 |
Generic |
25% | 25% | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Generic |
25% | 25% | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Generic |
25% | 25% | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
25% | 25% | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Generic |
25% | 25% | None |
MINOXIDIL 10MG TABLET |
1 |
Generic |
25% | 25% | None |
MINOXIDIL 2.5MG TABLET |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
25% | 25% | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Generic |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Generic |
25% | 25% | Q:30 /30Days |
misoprostol 100 mcg tablet |
1 |
Generic |
25% | 25% | None |
misoprostol 200 mcg tablet |
1 |
Generic |
25% | 25% | None |
MITOMYCIN 20 MG VIAL |
3* |
Non-Preferred Brand |
25% | 25% | P |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Modafinil 100 mg tablet [Provigil] |
3* |
Non-Preferred Brand |
25% | 25% | P Q:60 /30Days |
Modafinil 200 mg tablet [Provigil] |
3* |
Non-Preferred Brand |
25% | 25% | P Q:60 /30Days |
Modicon 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
3* |
Non-Preferred Brand |
25% | 25% | None |
Moexipril hcl 15 mg tablet |
1 |
Generic |
25% | 25% | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Generic |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Generic |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Generic |
25% | 25% | None |
MOLINDONE HCL 10 MG TABLET [Moban] |
3* |
Non-Preferred Brand |
25% | 25% | P Q:240 /30Days |
MOLINDONE HCL 25 MG TABLET [Moban] |
3* |
Non-Preferred Brand |
25% | 25% | P Q:270 /30Days |
MOLINDONE HCL 5 MG TABLET [Moban] |
3* |
Non-Preferred Brand |
25% | 25% | P Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOMETASONE FUROATE 0.1% CREAM |
1 |
Generic |
25% | 25% | None |
MOMETASONE FUROATE 0.1% OINT |
1 |
Generic |
25% | 25% | None |
MOMETASONE FUROATE 0.1% SOLN |
1 |
Generic |
25% | 25% | None |
MOMETASONE FUROATE 50 MCG SPRY |
2 |
Preferred Brand |
25% | 25% | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
3* |
Non-Preferred Brand |
25% | 25% | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
Generic |
25% | 25% | Q:30 /30Days |
montelukast sod 4 mg granules [Singulair] |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
montelukast sod 4 mg tab chew [Singulair] |
1 |
Generic |
25% | 25% | Q:30 /30Days |
montelukast sod 5 mg tab chew [Singulair] |
1 |
Generic |
25% | 25% | Q:30 /30Days |
MONUROL 3 GM SACHET |
3* |
Non-Preferred Brand |
25% | 25% | None |
MORPHINE 10 MG/ML ISECURE SYR |
2 |
Preferred Brand |
25% | 25% | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Morphine 2 mg/ml isecure syr |
2 |
Preferred Brand |
25% | 25% | Q:1800 /30Days |
Morphine 4 mg/ml isecure syr |
2 |
Preferred Brand |
25% | 25% | Q:900 /30Days |
MORPHINE 8 MG/ML ISECURE SYR |
2 |
Preferred Brand |
25% | 25% | Q:450 /30Days |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Generic |
25% | 25% | Q:180 /30Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1 |
Generic |
25% | 25% | Q:600 /30Days |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
1 |
Generic |
25% | 25% | Q:2700 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Generic |
25% | 25% | Q:120 /30Days |
MORPHINE SULFATE 15MG TABLETS |
1 |
Generic |
25% | 25% | Q:180 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Generic |
25% | 25% | Q:90 /30Days |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
1 |
Generic |
25% | 25% | Q:1350 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Generic |
25% | 25% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 30MG TABLETS |
1 |
Generic |
25% | 25% | Q:180 /30Days |
MORPHINE SULFATE ER 10 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 100 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 120 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 20 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 45 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
MORPHINE SULFATE ER 50 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 75 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 80 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE ER 90 MG CAP |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Generic |
25% | 25% | Q:120 /30Days |
MOXIFLOXACIN 400 MG/250 ML BAG [Avelox] |
3* |
Non-Preferred Brand |
25% | 25% | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
3* |
Non-Preferred Brand |
25% | 25% | None |
MOZOBIL 20 MG/ML VIAL |
4* |
Specialty Tier |
25% | N/A | P Q:10 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
mupirocin 2% cream |
3* |
Non-Preferred Brand |
25% | 25% | None |
MUPIROCIN 2% OINTMENT |
1 |
Generic |
25% | 25% | None |
MUSTARGEN 10 MG VIAL |
3* |
Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
4* |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
4* |
Specialty Tier |
25% | N/A | None |
MYCAMINE 50MG VIAL |
3* |
Non-Preferred Brand |
25% | 25% | None |
MYCOPHENOLATE 200 MG/ML SUSP |
2 |
Preferred Brand |
25% | 25% | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Generic |
25% | 25% | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Generic |
25% | 25% | P |
Mycophenolic Acid DR 180 mg tb |
2 |
Preferred Brand |
25% | 25% | P |
Mycophenolic Acid DR 360 mg tb |
2 |
Preferred Brand |
25% | 25% | P |
MYFORTIC 180MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P |
MYFORTIC 360MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | P |
MYORISAN 10 MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYORISAN 20 MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |
Myorisan 30 mg capsule |
3* |
Non-Preferred Brand |
25% | 25% | None |
MYORISAN 40 MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | None |