2016 Medicare Part D Plan Formulary Information |
Community Care's Partnership Program (HMO SNP) (H5207-001-0)
Benefit Details
|
The Community Care's Partnership Program (HMO SNP) (H5207-001-0) Formulary Drugs Starting with the Letter M in Kenosha County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $37.70 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 |
1 |
Tier 1 |
$0.00 | N/A | None |
Magnesium sulfate 50% vial |
1 |
Tier 1 |
$0.00 | N/A | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
Tier 1 |
$0.00 | N/A | None |
MAPROTILINE 25MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MAPROTILINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MAPROTILINE 75MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MARPLAN 10MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
MATULANE 50MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
MECLIZINE 12.5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MECLIZINE 25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
$0.00 | N/A | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | P |
MEKINIST 0.5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MEKINIST 2 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MELOXICAM 15 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MELOXICAM 7.5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
1 |
Tier 1 |
$0.00 | N/A | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
1 |
Tier 1 |
$0.00 | N/A | None |
MEMANTINE HCL 5 MG TABLET [Namenda] |
1 |
Tier 1 |
$0.00 | N/A | 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 |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.3MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MENEST 0.625MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MENEST 1.25MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MENEST 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MENHIBRIX VACCINE VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
MENOMUNE-A/C/Y/W-135 VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
MENVEO INJECTION KIT |
1 |
Tier 1 |
$0.00 | N/A | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
1 |
Tier 1 |
$0.00 | N/A | None |
Mesalamine 1 KIT per CARTON |
1 |
Tier 1 |
$0.00 | N/A | None |
Mesna 100 mg/ml vial |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESNEX 400MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MESTINON 60MG/5ML SYRUP |
1 |
Tier 1 |
$0.00 | N/A | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
METFORMIN HCL ER 1,000 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
$0.00 | N/A | None |
Metformin Hydrochloride 750mg/1 |
1 |
Tier 1 |
$0.00 | N/A | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Methadone Hydrochloride 10mg/5mL |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methadone Hydrochloride 5mg/5mL |
1 |
Tier 1 |
$0.00 | N/A | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
Tier 1 |
$0.00 | N/A | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Methenamine Hippurate 1g/1 |
1 |
Tier 1 |
$0.00 | N/A | None |
METHIMAZOLE 10 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METHIMAZOLE 5MG TABLETS |
1 |
Tier 1 |
$0.00 | N/A | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
methotrexate 1 gm vial |
1 |
Tier 1 |
$0.00 | N/A | P |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methotrexate 25 mg/ml vial |
1 |
Tier 1 |
$0.00 | N/A | P |
Methoxsalen 10 mg Capsule [8-MOP] |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLDOPA 250MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLDOPATE 250MG/5ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE 10 MG CHEW TB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE 2.5 MG CHEW TB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE 5 MG CHEW TB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE CD 10 MG CAP |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE CD 30 MG CAP |
1 |
Tier 1 |
$0.00 | N/A | None |
methylphenidate cd 50 mg cap |
1 |
Tier 1 |
$0.00 | N/A | None |
methylphenidate cd 60 mg cap |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE ER 18 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE ER 27 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE ER 36 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE ER 40 MG CAP |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE ER 54 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE LA 20 MG CAP |
1 |
Tier 1 |
$0.00 | N/A | None |
methylprednisolone 125 mg vial |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
methylprednisolone 40 mg vial |
1 |
Tier 1 |
$0.00 | N/A | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Tier 1 |
$0.00 | N/A | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
1 |
Tier 1 |
$0.00 | N/A | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
$0.00 | N/A | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
1 |
Tier 1 |
$0.00 | N/A | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL SUCCINATE ER 200 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
$0.00 | N/A | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
$0.00 | N/A | None |
metronidazole 375 mg capsule |
1 |
Tier 1 |
$0.00 | N/A | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
1 |
Tier 1 |
$0.00 | N/A | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Tier 1 |
$0.00 | N/A | None |
metronidazole topical 1% gel |
1 |
Tier 1 |
$0.00 | N/A | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
$0.00 | N/A | None |
METRONIDAZOLE VAGINAL GEL |
1 |
Tier 1 |
$0.00 | N/A | None |
MEXILETINE 150MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
MEXILETINE 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
MEXILETINE 250MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
MIACALCIN 400 UNIT/2 ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
MICONAZOLE 3 200MG SUPPOS. |
1 |
Tier 1 |
$0.00 | N/A | None |
MIDODRINE HCL 10MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
1 |
Tier 1 |
$0.00 | N/A | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | N/A | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Tier 1 |
$0.00 | N/A | None |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$0.00 | N/A | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
$0.00 | N/A | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
misoprostol 100 mcg tablet |
1 |
Tier 1 |
$0.00 | N/A | None |
misoprostol 200 mcg tablet |
1 |
Tier 1 |
$0.00 | N/A | None |
MITOMYCIN 20 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
Modafinil 100 mg tablet [Provigil] |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Modafinil 200 mg tablet [Provigil] |
1 |
Tier 1 |
$0.00 | N/A | P |
MOLINDONE HCL 10 MG TABLET [Moban] |
1 |
Tier 1 |
$0.00 | N/A | None |
MOLINDONE HCL 25 MG TABLET [Moban] |
1 |
Tier 1 |
$0.00 | N/A | None |
MOLINDONE HCL 5 MG TABLET [Moban] |
1 |
Tier 1 |
$0.00 | N/A | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE 10 MG/ML ISECURE SYR |
1 |
Tier 1 |
$0.00 | N/A | None |
Morphine 2 mg/ml isecure syr |
1 |
Tier 1 |
$0.00 | N/A | None |
Morphine 4 mg/ml isecure syr |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE 8 MG/ML ISECURE SYR |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
$0.00 | N/A | None |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 15MG TABLETS |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE 30MG TABLETS |
1 |
Tier 1 |
$0.00 | N/A | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
$0.00 | N/A | None |
MOZOBIL 20 MG/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
mupirocin 2% cream |
1 |
Tier 1 |
$0.00 | N/A | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYAMBUTOL 400 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | None |
MYCAMINE 50MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
1 |
Tier 1 |
$0.00 | N/A | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Tier 1 |
$0.00 | N/A | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
$0.00 | N/A | P |
MYRBETRIQ ER 25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S |
MYRBETRIQ ER 50 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | S |