2016 Medicare Part D Plan Formulary Information |
FHCP's Premier Plus Plan (HMO-POS) (H1035-011-0)
Benefit Details
|
The FHCP's Premier Plus Plan (HMO-POS) (H1035-011-0) Formulary Drugs Starting with the Letter M in Brevard County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $17.00 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 |
6 |
Tier 6 |
25% | N/A | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
6 |
Tier 6 |
25% | N/A | P |
MALATHION 0.5% LOTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /7Days |
MAPROTILINE 25MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Tier 4 |
$80.00 | $237.00 | None |
MATULANE 50MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
MECLIZINE 25 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
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 |
Tier 1 |
$0.00 | $0.00 | P |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
6 |
Tier 6 |
25% | N/A | P |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEGESTROL 20MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEKINIST 0.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
MEKINIST 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
MELOXICAM 15 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MELOXICAM 7.5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | 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 |
Tier 2 |
$7.00 | $18.00 | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEMANTINE HCL 5 MG TABLET [Namenda] |
2 |
Tier 2 |
$7.00 | $18.00 | 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 |
6 |
Tier 6 |
25% | N/A | None |
MENEST 0.3MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
MENEST 0.625MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
MENEST 1.25MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
MENEST 2.5MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
MENHIBRIX VACCINE VIAL |
6 |
Tier 6 |
25% | N/A | None |
MENOMUNE-A/C/Y/W-135 VIAL |
6 |
Tier 6 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENVEO INJECTION KIT |
6 |
Tier 6 |
25% | N/A | None |
Meperidine Hydrochloride 100mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Meperidine Hydrochloride 50mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Meperidine Hydrochloride 50mg/mL 25 VIAL per CARTON / 1 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | P |
MEPROBAMATE 200 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEPROBAMATE 400 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MERCAPTOPURINE 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
6 |
Tier 6 |
25% | N/A | None |
Mesalamine 1 KIT per CARTON |
2 |
Tier 2 |
$7.00 | $18.00 | Q:1680 /28Days |
Mesna 100 mg/ml vial |
6 |
Tier 6 |
25% | N/A | None |
MESNEX 400MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESTINON 180MG TIMESPAN |
3 |
Tier 3 |
$40.00 | $117.00 | None |
METAPROTERENOL 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Metformin Hydrochloride 750mg/1 |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHADONE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methadone Hydrochloride 5mg/5mL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
6 |
Tier 6 |
25% | N/A | P |
METHAZOLAMIDE 25MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHIMAZOLE 10 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHIMAZOLE 5MG TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | P |
METHOCARBAMOL 750MG TABLET (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | P |
METHOTREXATE 2.5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Methotrexate 25 mg/ml vial |
6 |
Tier 6 |
25% | N/A | None |
Methoxsalen 10 mg Capsule [8-MOP] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA 250MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHYLPHENIDATE 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHYLPHENIDATE 20MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHYLPHENIDATE CD 10 MG CAP |
2 |
Tier 2 |
$7.00 | $18.00 | Q:31 /31Days |
methylphenidate cd 50 mg cap |
2 |
Tier 2 |
$7.00 | $18.00 | Q:31 /31Days |
methylphenidate cd 60 mg cap |
2 |
Tier 2 |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE ER 18 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE ER 27 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE ER 36 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE ER 54 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | Q:31 /31Days |
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:93 /31Days |
methylprednisolone 125 mg vial |
6 |
Tier 6 |
25% | N/A | P |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
6 |
Tier 6 |
25% | N/A | P |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
6 |
Tier 6 |
25% | N/A | P |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOCLOPRAMIDE 5 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | P |
METOLAZONE 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METOLAZONE 2.5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METOLAZONE 5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
6 |
Tier 6 |
25% | N/A | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Tier 2 |
$7.00 | $18.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% LOTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
6 |
Tier 6 |
25% | N/A | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
metronidazole topical 1% gel |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:30 /30Days |
METRONIDAZOLE VAGINAL GEL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:70 /10Days |
MEXILETINE 150MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEXILETINE 200MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIACALCIN 400 UNIT/2 ML VIAL |
4 |
Tier 4 |
$80.00 | $237.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Migergot suppository |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /14Days |
MINOCYCLINE 50MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MINOXIDIL 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
misoprostol 200 mcg tablet |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MITOMYCIN 20 MG VIAL |
6 |
Tier 6 |
25% | N/A | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
6 |
Tier 6 |
25% | N/A | None |
Modafinil 100 mg tablet [Provigil] |
2 |
Tier 2 |
$7.00 | $18.00 | P Q:31 /31Days |
Modafinil 200 mg tablet [Provigil] |
2 |
Tier 2 |
$7.00 | $18.00 | P Q:31 /31Days |
MOLINDONE HCL 10 MG TABLET [Moban] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MOLINDONE HCL 25 MG TABLET [Moban] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOLINDONE HCL 5 MG TABLET [Moban] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MOMETASONE FUROATE 0.1% CREAM |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
MOMETASONE FUROATE 0.1% OINT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
montelukast sod 4 mg granules [Singulair] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
montelukast sod 4 mg tab chew [Singulair] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
montelukast sod 5 mg tab chew [Singulair] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 15MG TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE 30MG TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
MOVANTIK 12.5 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | P |
MOVANTIK 25 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | P |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | Q:3 /7Days |
MOZOBIL 20 MG/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Tier 4 |
$80.00 | $237.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUPIROCIN 2% OINTMENT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:22 /30Days |
MYCOPHENOLATE 200 MG/ML SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Tier 2 |
$7.00 | $18.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Mycophenolic Acid DR 180 mg tb |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Mycophenolic Acid DR 360 mg tb |
5 |
Tier 5 |
33% | N/A | P |
MYORISAN 10 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | P |
MYRBETRIQ ER 25 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
MYRBETRIQ ER 50 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |