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2016 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Symphonix PrimeSaver Rx (PDP) (S0522-063-0)
Tier 1 (193)
Tier 2 (782)
Tier 3 (816)
Tier 4 (1204)
Tier 5 (736)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2016 Medicare Part D Plan Formulary Information
Symphonix PrimeSaver Rx (PDP) (S0522-063-0)
Benefit Details           
The Symphonix PrimeSaver Rx (PDP) (S0522-063-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 30 which includes: OR WA
Plan Monthly Premium: $38.60 Deductible: $200 Qualifies for LIS: No
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 20%20%None
Magnesium sulfate 50% vial   2* Generic $6.00$18.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   2* Generic $6.00$18.00None
MAKENA 250 MG/ML VIAL   5 Specialty Tier 28%N/AP
MALATHION 0.5% LOTION   4 Non-Preferred Brand 40%40%None
MAPROTILINE 25MG TABLET   3 Preferred Brand 20%20%None
MAPROTILINE 50MG TABLET   4 Non-Preferred Brand 40%40%None
MAPROTILINE 75MG TABLET   4 Non-Preferred Brand 40%40%None
MARLISSA-28 TABLET   2* Generic $6.00$18.00None
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MATULANE 50MG CAPSULE   5 Specialty Tier 28%N/ANone
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 40%40%None
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 40%40%None
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 40%40%None
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 40%40%None
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 40%40%None
MECLIZINE 12.5 MG TABLET   2* Generic $6.00$18.00None
MECLIZINE 25 MG TABLET   2* Generic $6.00$18.00None
MECLOFENAMATE 100MG CAPSULE   4 Non-Preferred Brand 40%40%None
MECLOFENAMATE 50MG CAPSULE   4 Non-Preferred Brand 40%40%None
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE   1* Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE   1* Preferred Generic $1.00$3.00None
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE   1* Preferred Generic $1.00$3.00None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   2* Generic $6.00$18.00None
MEFENAMIC ACID 250 MG CAPSULE   4 Non-Preferred Brand 40%40%None
MEFLOQUINE HCL 250MG TABLET 25 BOT   2* Generic $6.00$18.00None
MEGACE ES 625MG/5ML SUSP   5 Specialty Tier 28%N/ANone
MEGESTROL 20MG TABLET   2* Generic $6.00$18.00None
MEGESTROL 625 MG/5 ML SUSP   4 Non-Preferred Brand 40%40%None
MEGESTROL ACETATE 40MG TABLET (250 CT)   2* Generic $6.00$18.00None
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC   3 Preferred Brand 20%20%None
MEKINIST 0.5 MG TABLET   5 Specialty Tier 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEKINIST 2 MG TABLET   5 Specialty Tier 28%N/AP
MELOXICAM 15 MG TABLET   1* Preferred Generic $1.00$3.00None
MELOXICAM 7.5 MG TABLET   1* Preferred Generic $1.00$3.00None
MELOXICAM 7.5MG/5ML SUSPENSION ORAL   4 Non-Preferred Brand 40%40%None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   5 Specialty Tier 28%N/ANone
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   4 Non-Preferred Brand 40%40%P
MEMANTINE HCL 10 MG TABLET [Namenda]   4 Non-Preferred Brand 40%40%P
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   4 Non-Preferred Brand 40%40%P
MEMANTINE HCL 5 MG TABLET [Namenda]   4 Non-Preferred Brand 40%40%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   4 Non-Preferred Brand 40%40%None
MENEST 0.3MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MENEST 0.625MG TABLET   3 Preferred Brand 20%20%None
MENEST 1.25MG TABLET   3 Preferred Brand 20%20%None
MENEST 2.5MG TABLET   4 Non-Preferred Brand 40%40%None
MENHIBRIX VACCINE VIAL   3 Preferred Brand 20%20%None
MENOMUNE-A/C/Y/W-135 VIAL   4 Non-Preferred Brand 40%40%None
MENVEO INJECTION KIT   4 Non-Preferred Brand 40%40%None
MEPROBAMATE 200 MG TABLET   3 Preferred Brand 20%20%P
MEPROBAMATE 400 MG TABLET   4 Non-Preferred Brand 40%40%P
MEPRON 750MG/5ML ORAL SUSP   5 Specialty Tier 28%N/ANone
MERCAPTOPURINE 50MG TABLET   3 Preferred Brand 20%20%None
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Mesalamine 1 KIT per CARTON   4 Non-Preferred Brand 40%40%None
Mesna 100 mg/ml vial   4 Non-Preferred Brand 40%40%None
MESNEX 400MG TABLET   5 Specialty Tier 28%N/ANone
MESTINON 180MG TIMESPAN   4 Non-Preferred Brand 40%40%None
MESTINON 60MG/5ML SYRUP   4 Non-Preferred Brand 40%40%None
Metadate er 20 mg tablet   4 Non-Preferred Brand 40%40%Q:90
/30Days
METAPROTERENOL 20MG TABLET   4 Non-Preferred Brand 40%40%None
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   2* Generic $6.00$18.00None
METFORMIN HCL 1,000 MG TABLET   1* Preferred Generic $1.00$3.00Q:75
/30Days
METFORMIN HCL 500MG TABLET (1000 CT)   1* Preferred Generic $1.00$3.00Q:150
/30Days
METFORMIN HCL ER 1,000 MG TAB   4 Non-Preferred Brand 40%40%Q:120
/30Days
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 $1.00$3.00Q:120
/30Days
Metformin Hydrochloride 750mg/1   2* Generic $6.00$18.00Q:60
/30Days
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE   1* Preferred Generic $1.00$3.00Q:90
/30Days
METHADONE HCL 5MG TABLET (100 CT)   2* Generic $6.00$18.00Q:360
/30Days
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE   3 Preferred Brand 20%20%Q:360
/30Days
Methadone Hydrochloride 10mg/5mL   3 Preferred Brand 20%20%Q:1800
/30Days
Methadone Hydrochloride 5mg/5mL   3 Preferred Brand 20%20%Q:3600
/30Days
METHADONE HYDROCHLORIDE INJECTION 10MG/ML   5 Specialty Tier 28%N/ANone
METHAZOLAMIDE 25MG TABLET   4 Non-Preferred Brand 40%40%None
METHAZOLAMIDE 50MG TABLET   4 Non-Preferred Brand 40%40%None
Methenamine Hippurate 1g/1   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHIMAZOLE 10 MG TABLET   2* Generic $6.00$18.00None
METHIMAZOLE 5MG TABLETS   1* Preferred Generic $1.00$3.00None
Methocarbamol 500mg 100 TABLET BOTTLE   3 Preferred Brand 20%20%P Q:270
/30Days
METHOCARBAMOL 750MG TABLET (500 CT)   3 Preferred Brand 20%20%P Q:180
/30Days
methotrexate 1 gm vial   4 Non-Preferred Brand 40%40%None
METHOTREXATE 2.5MG TABLET   3 Preferred Brand 20%20%None
Methotrexate 25 mg/ml vial   2* Generic $6.00$18.00None
Methoxsalen 10 mg Capsule [8-MOP]   5 Specialty Tier 28%N/ANone
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   4 Non-Preferred Brand 40%40%None
METHSCOPOLAMINE BROMIDE 5 MG TAB   4 Non-Preferred Brand 40%40%None
METHYCLOTHIAZIDE 5MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE   5 Specialty Tier 28%N/ANone
METHYLIN 10 MG CHEWABLE   4 Non-Preferred Brand 40%40%Q:180
/30Days
METHYLIN 2.5 MG CHEWABLE TAB   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLIN 5 MG CHEWABLE TABLET   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLPHENIDATE 10 MG CHEW TB   4 Non-Preferred Brand 40%40%Q:180
/30Days
METHYLPHENIDATE 10MG TABLET   3 Preferred Brand 20%20%Q:90
/30Days
METHYLPHENIDATE 2.5 MG CHEW TB   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLPHENIDATE 20MG TABLET   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLPHENIDATE 5 MG CHEW TB   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLPHENIDATE CD 10 MG CAP   4 Non-Preferred Brand 40%40%None
METHYLPHENIDATE CD 30 MG CAP   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
methylphenidate cd 50 mg cap   4 Non-Preferred Brand 40%40%None
methylphenidate cd 60 mg cap   4 Non-Preferred Brand 40%40%None
METHYLPHENIDATE ER 18 MG TAB   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLPHENIDATE ER 27 MG TAB   4 Non-Preferred Brand 40%40%Q:60
/30Days
METHYLPHENIDATE ER 36 MG TAB   4 Non-Preferred Brand 40%40%None
METHYLPHENIDATE ER 40 MG CAP   4 Non-Preferred Brand 40%40%None
METHYLPHENIDATE ER 54 MG TAB   4 Non-Preferred Brand 40%40%None
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE   4 Non-Preferred Brand 40%40%Q:900
/30Days
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE   3 Preferred Brand 20%20%Q:90
/30Days
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE   4 Non-Preferred Brand 40%40%Q:1800
/30Days
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE   4 Non-Preferred Brand 40%40%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE   4 Non-Preferred Brand 40%40%Q:90
/30Days
METHYLPHENIDATE LA 20 MG CAP   4 Non-Preferred Brand 40%40%None
methylprednisolone 125 mg vial   3 Preferred Brand 20%20%None
METHYLPREDNISOLONE 16MG TABLET   2* Generic $6.00$18.00None
METHYLPREDNISOLONE 32MG TABLET   2* Generic $6.00$18.00None
methylprednisolone 40 mg vial   4 Non-Preferred Brand 40%40%None
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   2* Generic $6.00$18.00None
Methylprednisolone 4mg/1 100 TABLET BOTTLE   2* Generic $6.00$18.00None
METHYLPREDNISOLONE 8 MG ORAL TABLET   2* Generic $6.00$18.00None
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS   2* Generic $6.00$18.00None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   2* Generic $6.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METIPRANOLOL 0.3% EYE DROPS   2* Generic $6.00$18.00None
Metoclopramide 10mg/1 500 TABLET BOTTLE   1* Preferred Generic $1.00$3.00None
METOCLOPRAMIDE 5 MG TABLET   1* Preferred Generic $1.00$3.00None
METOCLOPRAMIDE 5 MG/5 ML SOLN   2* Generic $6.00$18.00None
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL   2* Generic $6.00$18.00None
METOLAZONE 10MG TABLET   3 Preferred Brand 20%20%None
METOLAZONE 2.5MG TABLET   2* Generic $6.00$18.00None
METOLAZONE 5MG TABLET   2* Generic $6.00$18.00None
METOPROLOL SUCC ER 100 MG TAB   3 Preferred Brand 20%20%None
METOPROLOL SUCC ER 50 MG TAB   2* Generic $6.00$18.00None
METOPROLOL SUCCINATE ER 200 MG TAB   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL SUCCINATE ER 25 MG TAB   2* Generic $6.00$18.00None
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE   2* Generic $6.00$18.00None
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1* Preferred Generic $1.00$3.00None
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT   2* Generic $6.00$18.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1* Preferred Generic $1.00$3.00None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1* Preferred Generic $1.00$3.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   3 Preferred Brand 20%20%None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   3 Preferred Brand 20%20%None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   2* Generic $6.00$18.00None
METRONIDAZOLE 0.75% CREAM   4 Non-Preferred Brand 40%40%None
METRONIDAZOLE 0.75% LOTION   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
metronidazole 375 mg capsule   4 Non-Preferred Brand 40%40%None
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG   2* Generic $6.00$18.00None
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL   2* Generic $6.00$18.00None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL   2* Generic $6.00$18.00None
metronidazole topical 1% gel   4 Non-Preferred Brand 40%40%None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   4 Non-Preferred Brand 40%40%None
METRONIDAZOLE VAGINAL GEL   2* Generic $6.00$18.00None
MEXILETINE 150MG CAPSULE   3 Preferred Brand 20%20%None
MEXILETINE 200MG CAPSULE   3 Preferred Brand 20%20%None
MEXILETINE 250MG CAPSULE   3 Preferred Brand 20%20%None
MIACALCIN 400 UNIT/2 ML VIAL   5 Specialty Tier 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MICONAZOLE 3 200MG SUPPOS.   3 Preferred Brand 20%20%None
MICROGESTIN 21 1-20 TABLET   2* Generic $6.00$18.00None
MICROGESTIN 21 1.5-30 TAB   2* Generic $6.00$18.00None
MICROGESTIN FE 1-20 TABLET   2* Generic $6.00$18.00None
MICROGESTIN FE 1.5-30 TAB   2* Generic $6.00$18.00None
MIDODRINE HCL 10MG TABLET   3 Preferred Brand 20%20%None
MIDODRINE HCL 2.5MG TABLET   3 Preferred Brand 20%20%None
MIDODRINE HCL 5MG TABLET (100 CT)   3 Preferred Brand 20%20%None
Migergot suppository   5 Specialty Tier 28%N/AQ:20
/28Days
Millipred 5 mg tablet   4 Non-Preferred Brand 40%40%None
Mimvey 1; 0.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 FILM COATED TABLETS in BLISTER PACK   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINITRAN 0.1 MG/HR PATCH   2* Generic $6.00$18.00None
MINITRAN 0.2 MG/HR PATCH   2* Generic $6.00$18.00None
MINITRAN 0.4 MG/HR PATCH   2* Generic $6.00$18.00None
MINITRAN 0.6 MG/HR PATCH   2* Generic $6.00$18.00None
MINOCYCLINE 50MG CAPSULE   2* Generic $6.00$18.00None
MINOCYCLINE HCL 75MG CAPSULE   2* Generic $6.00$18.00None
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC   2* Generic $6.00$18.00None
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 40%40%None
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 40%40%None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   4 Non-Preferred Brand 40%40%None
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 135MG   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 45MG   4 Non-Preferred Brand 40%40%None
MINOCYCLINE HYDROCHLORIDE TABLETS EXTENDED RELEASE 90MG   4 Non-Preferred Brand 40%40%None
MINOXIDIL 10MG TABLET   2* Generic $6.00$18.00None
MINOXIDIL 2.5MG TABLET   2* Generic $6.00$18.00None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   2* Generic $6.00$18.00None
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE   2* Generic $6.00$18.00None
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   2* Generic $6.00$18.00None
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE   2* Generic $6.00$18.00None
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand 20%20%None
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX   2* Generic $6.00$18.00None
MIRTAZAPINE TABLET 30MG (30 CT)   2* Generic $6.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRVASO TOP GEL 0.33%   4 Non-Preferred Brand 40%40%None
misoprostol 100 mcg tablet   2* Generic $6.00$18.00None
misoprostol 200 mcg tablet   3 Preferred Brand 20%20%None
MITOMYCIN 20 MG VIAL   5 Specialty Tier 28%N/ANone
MITOXANTRONE INJECTION 2MG 125ML VIAL   3 Preferred Brand 20%20%None
Modafinil 100 mg tablet [Provigil]   4 Non-Preferred Brand 40%40%P Q:120
/30Days
Modafinil 200 mg tablet [Provigil]   4 Non-Preferred Brand 40%40%P Q:60
/30Days
Moderiba 200 mg tablet   3 Preferred Brand 20%20%None
Moderiba 400-400 mg dosepack   3 Preferred Brand 20%20%None
Moderiba 600-600 mg dosepack   3 Preferred Brand 20%20%None
Moexipril hcl 15 mg tablet   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE   2* Generic $6.00$18.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   2* Generic $6.00$18.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   2* Generic $6.00$18.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   2* Generic $6.00$18.00None
MOLINDONE HCL 10 MG TABLET [Moban]   4 Non-Preferred Brand 40%40%None
MOLINDONE HCL 25 MG TABLET [Moban]   4 Non-Preferred Brand 40%40%None
MOLINDONE HCL 5 MG TABLET [Moban]   4 Non-Preferred Brand 40%40%None
MOMETASONE FUROATE 0.1% CREAM   2* Generic $6.00$18.00None
MOMETASONE FUROATE 0.1% OINT   2* Generic $6.00$18.00None
MOMETASONE FUROATE 0.1% SOLN   2* Generic $6.00$18.00None
MOMETASONE FUROATE 50 MCG SPRY   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   2* Generic $6.00$18.00None
MONTELUKAST SOD 10 MG TABLET [Singulair]   2* Generic $6.00$18.00Q:30
/30Days
montelukast sod 4 mg granules [Singulair]   4 Non-Preferred Brand 40%40%Q:30
/30Days
montelukast sod 4 mg tab chew [Singulair]   2* Generic $6.00$18.00Q:30
/30Days
montelukast sod 5 mg tab chew [Singulair]   2* Generic $6.00$18.00Q:30
/30Days
MORPHINE 10 MG/ML ISECURE SYR   3 Preferred Brand 20%20%None
Morphine 2 mg/ml isecure syr   3 Preferred Brand 20%20%None
Morphine 4 mg/ml isecure syr   3 Preferred Brand 20%20%None
MORPHINE 8 MG/ML ISECURE SYR   3 Preferred Brand 20%20%None
MORPHINE SULFATE 100MG TABLET SA   4 Non-Preferred Brand 40%40%Q:180
/30Days
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE   3 Preferred Brand 20%20%Q:540
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION   3 Preferred Brand 20%20%Q:3600
/30Days
MORPHINE SULFATE 15MG TABLET SA   3 Preferred Brand 20%20%Q:120
/30Days
MORPHINE SULFATE 15MG TABLETS   3 Preferred Brand 20%20%Q:360
/30Days
MORPHINE SULFATE 200MG TABLET SA   4 Non-Preferred Brand 40%40%Q:180
/30Days
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION   3 Preferred Brand 20%20%Q:2700
/30Days
MORPHINE SULFATE 30MG TABLET SA   3 Preferred Brand 20%20%Q:120
/30Days
MORPHINE SULFATE 30MG TABLETS   3 Preferred Brand 20%20%Q:360
/30Days
MORPHINE SULFATE ER 10 MG CAP   4 Non-Preferred Brand 40%40%Q:120
/30Days
MORPHINE SULFATE ER 100 MG CAP   5 Specialty Tier 28%N/AQ:180
/30Days
MORPHINE SULFATE ER 20 MG CAP   4 Non-Preferred Brand 40%40%Q:120
/30Days
MORPHINE SULFATE ER 30 MG CAP   4 Non-Preferred Brand 40%40%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE ER 50 MG CAP   4 Non-Preferred Brand 40%40%Q:120
/30Days
MORPHINE SULFATE ER 60 MG CAP   4 Non-Preferred Brand 40%40%Q:120
/30Days
MORPHINE SULFATE ER 80 MG CAP   4 Non-Preferred Brand 40%40%Q:120
/30Days
MORPHINE SULFATE TABLET ER 60MG (100 CT)   4 Non-Preferred Brand 40%40%Q:120
/30Days
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   3 Preferred Brand 20%20%None
MOXIFLOXACIN HCL 400 MG TABLET [Avelox]   4 Non-Preferred Brand 40%40%None
MOZOBIL 20 MG/ML VIAL   5 Specialty Tier 28%N/AP
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE   3 Preferred Brand 20%20%Q:60
/30Days
MUPIROCIN 2% OINTMENT   2* Generic $6.00$18.00None
MUSTARGEN 10 MG VIAL   5 Specialty Tier 28%N/ANone
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK   3 Preferred Brand 20%20%P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT   3 Preferred Brand 20%20%P
Mycophenolic Acid DR 180 mg tb   4 Non-Preferred Brand 40%40%P
Mycophenolic Acid DR 360 mg tb   4 Non-Preferred Brand 40%40%P
MYFORTIC 360MG TABLET   5 Specialty Tier 28%N/AP
MYORISAN 20 MG CAPSULE   4 Non-Preferred Brand 40%40%None
Myorisan 30 mg capsule   4 Non-Preferred Brand 40%40%None
MYORISAN 40 MG CAPSULE   4 Non-Preferred Brand 40%40%None
MYRBETRIQ ER 25 MG TABLET   4 Non-Preferred Brand 40%40%None
MYRBETRIQ ER 50 MG TABLET   4 Non-Preferred Brand 40%40%None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Symphonix PrimeSaver Rx (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $360 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2016 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.