2016 Medicare Part D Plan Formulary Information |
Optimum Emerald Full (HMO SNP) (H5594-017-0)
Benefit Details
|
The Optimum Emerald Full (HMO SNP) (H5594-017-0) Formulary Drugs Starting with the Letter M in Polk County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $28.00 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 |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Magnesium sulfate 50% vial |
1* |
Generic |
$0.00 | $0.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1* |
Generic |
$0.00 | $0.00 | None |
MALARONE 250-100MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MALARONE 62.5-25MG PED TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MAPROTILINE 25MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MARPLAN 10MG TABLET (100 CT) |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MATULANE 50MG CAPSULE |
3 |
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 |
MECLIZINE 12.5 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
MECLIZINE 25 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1* |
Generic |
$0.00 | $0.00 | Q:1 /90Days |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MEGACE ES 625MG/5ML SUSP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:600 /30Days |
MEGESTROL 20MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEKINIST 0.5 MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
MEKINIST 2 MG TABLET |
4 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
MELOXICAM 15 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
MEMANTINE HCL 10 MG TABLET [Namenda] |
1* |
Generic |
$0.00 | $0.00 | Q:60 /30Days |
MEMANTINE HCL 5 MG TABLET [Namenda] |
1* |
Generic |
$0.00 | $0.00 | 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 |
$95.00 | $285.00 | None |
MENEST 0.3MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENEST 0.625MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENEST 1.25MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MENEST 2.5MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MENOSTAR 14 MCG/DAY PATCH |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MENVEO INJECTION KIT |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MEPROBAMATE 200 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | S Q:120 /30Days |
MEPROBAMATE 400 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | S Q:240 /30Days |
MEPRON 750MG/5ML ORAL SUSP |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MERCAPTOPURINE 50MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Mesalamine 1 KIT per CARTON |
1* |
Generic |
$0.00 | $0.00 | None |
Mesna 100 mg/ml vial |
1* |
Generic |
$0.00 | $0.00 | P |
MESNEX 400MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESTINON 180MG TIMESPAN |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MESTINON 60MG/5ML SYRUP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METAPROTERENOL 10MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1* |
Generic |
$0.00 | $0.00 | None |
Metaxalone 400 MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METAXALONE 800 MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METFORMIN HCL 1,000 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
METFORMIN HCL ER 1,000 MG TAB |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metformin Hydrochloride 750mg/1 |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
METHADONE HCL 5MG TABLET (100 CT) |
1* |
Generic |
$0.00 | $0.00 | Q:90 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | Q:360 /30Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1* |
Generic |
$0.00 | $0.00 | P |
METHAZOLAMIDE 25MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Methenamine Hippurate 1g/1 |
1* |
Generic |
$0.00 | $0.00 | None |
METHIMAZOLE 10 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METHIMAZOLE 5MG TABLETS |
1* |
Generic |
$0.00 | $0.00 | None |
METHITEST 10MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methotrexate 1 gm vial |
1* |
Generic |
$0.00 | $0.00 | P |
METHOTREXATE 2.5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | P |
Methotrexate 25 mg/ml vial |
1* |
Generic |
$0.00 | $0.00 | P |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METHYLDOPATE 250MG/5ML VIAL |
1* |
Generic |
$0.00 | $0.00 | P |
METHYLPHENIDATE 10MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPHENIDATE CD 30 MG CAP |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
METHYLPHENIDATE ER 40 MG CAP |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPHENIDATE LA 20 MG CAP |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
methylprednisolone 125 mg vial |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
methylprednisolone 40 mg vial |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1* |
Generic |
$0.00 | $0.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
1* |
Generic |
$0.00 | $0.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
1* |
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 |
1* |
Generic |
$0.00 | $0.00 | P |
METOLAZONE 10MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METOLAZONE 2.5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METOLAZONE 5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
METOPROLOL SUCCINATE ER 200 MG TAB |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
METOPROLOL SUCCINATE ER 25 MG TAB |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
1* |
Generic |
$0.00 | $0.00 | P |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT |
1* |
Generic |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METRONIDAZOLE 0.75% LOTION |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1* |
Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1* |
Generic |
$0.00 | $0.00 | None |
metronidazole topical 1% gel |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
METRONIDAZOLE VAGINAL GEL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MEXILETINE 150MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
MEXILETINE 200MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
MEXILETINE 250MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
MIACALCIN 400 UNIT/2 ML VIAL |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MICROGESTIN 21 1.5-30 TAB |
1* |
Generic |
$0.00 | $0.00 | None |
MIDODRINE HCL 10MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Migergot suppository |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Millipred 5 mg tablet |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MINOCYCLINE 50MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
1* |
Generic |
$0.00 | $0.00 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1* |
Generic |
$0.00 | $0.00 | None |
MINOXIDIL 10MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
MINOXIDIL 2.5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1* |
Generic |
$0.00 | $0.00 | None |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1* |
Generic |
$0.00 | $0.00 | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1* |
Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
misoprostol 100 mcg tablet |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
misoprostol 200 mcg tablet |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
MITOMYCIN 20 MG VIAL |
1* |
Generic |
$0.00 | $0.00 | P |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
Modafinil 100 mg tablet [Provigil] |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
Modafinil 200 mg tablet [Provigil] |
4 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOLINDONE HCL 10 MG TABLET [Moban] |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOLINDONE HCL 25 MG TABLET [Moban] |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOLINDONE HCL 5 MG TABLET [Moban] |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOMETASONE FUROATE 0.1% CREAM |
1* |
Generic |
$0.00 | $0.00 | None |
MOMETASONE FUROATE 0.1% OINT |
1* |
Generic |
$0.00 | $0.00 | None |
MOMETASONE FUROATE 0.1% SOLN |
1* |
Generic |
$0.00 | $0.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
montelukast sod 4 mg tab chew [Singulair] |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
montelukast sod 5 mg tab chew [Singulair] |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
MONUROL 3 GM SACHET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
MORPHINE SULFATE 15MG TABLETS |
1* |
Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
1* |
Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
MORPHINE SULFATE 30MG TABLETS |
1* |
Generic |
$0.00 | $0.00 | None |
MORPHINE SULFATE ER 120 MG CAP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MORPHINE SULFATE ER 30 MG CAP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MORPHINE SULFATE ER 45 MG CAP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MORPHINE SULFATE ER 60 MG CAP |
3 |
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 |
MORPHINE SULFATE ER 75 MG CAP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MORPHINE SULFATE ER 90 MG CAP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
MOVANTIK 12.5 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
MOVANTIK 25 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:14 /14Days |
MOZOBIL 20 MG/ML VIAL |
4 |
Specialty Tier |
25% | 25% | P Q:8 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MUPIROCIN 2% OINTMENT |
1* |
Generic |
$0.00 | $0.00 | None |
MUSTARGEN 10 MG VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCAMINE 50MG VIAL |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MYCOBUTIN 150MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
MYFORTIC 180MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
MYFORTIC 360MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
MYRBETRIQ ER 25 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
MYRBETRIQ ER 50 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |