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2016 Medicare Part D Plan Formulary Information
SecureRx - Option 3 (PDP) (S8067-001-0) Benefit Details
The SecureRx - Option 3 (PDP) (S8067-001-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 6 which includes: PA WV Plan Monthly Premium: $78.80 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter M Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter M Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML	3	Preferred Brand	$38.00	$114.00	None
Magnesium sulfate 50% vial	2	Generic	$15.00	$45.00	None
MAGNESIUM SULFATE INJECTION 5 GM/10ML	2	Generic	$15.00	$45.00	None
MALATHION 0.5% LOTION	4	Non-Preferred Brand	$89.00	$267.00	None
MAPROTILINE 25MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
MAPROTILINE 50MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
MAPROTILINE 75MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
MARLISSA-28 TABLET	3	Preferred Brand	$38.00	$114.00	None
MARPLAN 10MG TABLET (100 CT)	4	Non-Preferred Brand	$89.00	$267.00	Q:180 /30Days
MATULANE 50MG CAPSULE	5	Specialty Tier	33%	N/A	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	Preferred Brand	$38.00	$114.00	None
MECLIZINE 12.5 MG TABLET	2	Generic	$15.00	$45.00	None
MECLIZINE 25 MG TABLET	2	Generic	$15.00	$45.00	None
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE	1	Preferred Generic	$4.00	$12.00	None
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE	1	Preferred Generic	$4.00	$12.00	None
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE	1	Preferred Generic	$4.00	$12.00	None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN	2	Generic	$15.00	$45.00	None
MEFLOQUINE HCL 250MG TABLET 25 BOT	3	Preferred Brand	$38.00	$114.00	None
MEGESTROL 20MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	P
MEGESTROL 625 MG/5 ML SUSP	5	Specialty Tier	33%	N/A	P
MEGESTROL ACETATE 40MG TABLET (250 CT)	4	Non-Preferred Brand	$89.00	$267.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	$89.00	$267.00	P
MEKINIST 0.5 MG TABLET	5	Specialty Tier	33%	N/A	P
MEKINIST 2 MG TABLET	5	Specialty Tier	33%	N/A	P
MELOXICAM 15 MG TABLET	1	Preferred Generic	$4.00	$12.00	None
MELOXICAM 7.5 MG TABLET	1	Preferred Generic	$4.00	$12.00	None
MELOXICAM 7.5MG/5ML SUSPENSION ORAL	4	Non-Preferred Brand	$89.00	$267.00	None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION	5	Specialty Tier	33%	N/A	P
MEMANTINE HCL 10 MG TABLET [Namenda]	4	Non-Preferred Brand	$89.00	$267.00	P
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]	3	Preferred Brand	$38.00	$114.00	P
MEMANTINE HCL 5 MG TABLET [Namenda]	4	Non-Preferred Brand	$89.00	$267.00	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	3	Preferred Brand	$38.00	$114.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MENOMUNE-A/C/Y/W-135 VIAL	3	Preferred Brand	$38.00	$114.00	None
MENVEO INJECTION KIT	3	Preferred Brand	$38.00	$114.00	None
MERCAPTOPURINE 50MG TABLET	3	Preferred Brand	$38.00	$114.00	None
MEROPENEM 500MG/VIAL FOR INJECTION	4	Non-Preferred Brand	$89.00	$267.00	None
Mesalamine 1 KIT per CARTON	4	Non-Preferred Brand	$89.00	$267.00	None
Mesna 100 mg/ml vial	4	Non-Preferred Brand	$89.00	$267.00	P
MESNEX 400MG TABLET	5	Specialty Tier	33%	N/A	None
Metadate er 20 mg tablet	4	Non-Preferred Brand	$89.00	$267.00	Q:90 /30Days
METFORMIN HCL 1,000 MG TABLET	1	Preferred Generic	$4.00	$12.00	Q:75 /30Days
METFORMIN HCL 500MG TABLET (1000 CT)	1	Preferred Generic	$4.00	$12.00	Q:150 /30Days
METFORMIN HCL ER 500MG TABLET SR 24HR	1	Preferred Generic	$4.00	$12.00	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Metformin Hydrochloride 750mg/1	1	Preferred Generic	$4.00	$12.00	Q:60 /30Days
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE	1	Preferred Generic	$4.00	$12.00	Q:90 /30Days
METHADONE HCL 5MG TABLET (100 CT)	2	Generic	$15.00	$45.00	Q:240 /30Days
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE	2	Generic	$15.00	$45.00	Q:240 /30Days
Methadone Hydrochloride 10mg/5mL	3	Preferred Brand	$38.00	$114.00	Q:600 /30Days
Methadone Hydrochloride 5mg/5mL	3	Preferred Brand	$38.00	$114.00	Q:600 /30Days
METHAZOLAMIDE 25MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
METHAZOLAMIDE 50MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
Methenamine Hippurate 1g/1	3	Preferred Brand	$38.00	$114.00	None
METHIMAZOLE 10 MG TABLET	2	Generic	$15.00	$45.00	None
METHIMAZOLE 5MG TABLETS	2	Generic	$15.00	$45.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
methotrexate 1 gm vial	2	Generic	$15.00	$45.00	P
METHOTREXATE 2.5MG TABLET	3	Preferred Brand	$38.00	$114.00	None
Methotrexate 25 mg/ml vial	2	Generic	$15.00	$45.00	P
METHYCLOTHIAZIDE 5MG TABLET	3	Preferred Brand	$38.00	$114.00	None
Methylergonovine Maleate 0.2mg/1 28 TABLET BOTTLE	4	Non-Preferred Brand	$89.00	$267.00	None
METHYLPHENIDATE 10MG TABLET	3	Preferred Brand	$38.00	$114.00	Q:180 /30Days
METHYLPHENIDATE 20MG TABLET	3	Preferred Brand	$38.00	$114.00	Q:90 /30Days
Methylphenidate Hydrochloride 10mg/5mL 500 mL in 1 BOTTLE	4	Non-Preferred Brand	$89.00	$267.00	Q:900 /30Days
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE	3	Preferred Brand	$38.00	$114.00	Q:180 /30Days
Methylphenidate Hydrochloride 5mg/5mL 500 mL in 1 BOTTLE	4	Non-Preferred Brand	$89.00	$267.00	Q:1800 /30Days
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	$89.00	$267.00	Q:90 /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	$89.00	$267.00	Q:90 /30Days
methylprednisolone 125 mg vial	3	Preferred Brand	$38.00	$114.00	P
METHYLPREDNISOLONE 16MG TABLET	3	Preferred Brand	$38.00	$114.00	P
METHYLPREDNISOLONE 32MG TABLET	3	Preferred Brand	$38.00	$114.00	P
methylprednisolone 40 mg vial	3	Preferred Brand	$38.00	$114.00	P
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Generic	$15.00	$45.00	P
Methylprednisolone 4mg/1 100 TABLET BOTTLE	3	Preferred Brand	$38.00	$114.00	P
METHYLPREDNISOLONE 8 MG ORAL TABLET	3	Preferred Brand	$38.00	$114.00	P
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS	2	Generic	$15.00	$45.00	P
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM	3	Preferred Brand	$38.00	$114.00	None
METIPRANOLOL 0.3% EYE DROPS	3	Preferred Brand	$38.00	$114.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Metoclopramide 10mg/1 500 TABLET BOTTLE	1	Preferred Generic	$4.00	$12.00	None
METOCLOPRAMIDE 5 MG TABLET	1	Preferred Generic	$4.00	$12.00	None
METOCLOPRAMIDE 5 MG/5 ML SOLN	2	Generic	$15.00	$45.00	None
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL	2	Generic	$15.00	$45.00	None
METOLAZONE 10MG TABLET	3	Preferred Brand	$38.00	$114.00	None
METOLAZONE 2.5MG TABLET	3	Preferred Brand	$38.00	$114.00	None
METOLAZONE 5MG TABLET	3	Preferred Brand	$38.00	$114.00	None
METOPROLOL SUCC ER 100 MG TAB	3	Preferred Brand	$38.00	$114.00	Q:45 /30Days
METOPROLOL SUCC ER 50 MG TAB	3	Preferred Brand	$38.00	$114.00	Q:60 /30Days
METOPROLOL SUCCINATE ER 200 MG TAB	3	Preferred Brand	$38.00	$114.00	None
METOPROLOL SUCCINATE ER 25 MG TAB	3	Preferred Brand	$38.00	$114.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Metoprolol Tartrate 1mg/mL 3 AMPULE in 1 CARTON / 5 mL in 1 AMPULE	3	Preferred Brand	$38.00	$114.00	None
METOPROLOL TARTRATE 25MG TABLET (100 CT)	1	Preferred Generic	$4.00	$12.00	None
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT	3	Preferred Brand	$38.00	$114.00	None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)	1	Preferred Generic	$4.00	$12.00	None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)	1	Preferred Generic	$4.00	$12.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET	3	Preferred Brand	$38.00	$114.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET	3	Preferred Brand	$38.00	$114.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET	3	Preferred Brand	$38.00	$114.00	None
METRONIDAZOLE 0.75% CREAM	4	Non-Preferred Brand	$89.00	$267.00	None
METRONIDAZOLE 0.75% LOTION	4	Non-Preferred Brand	$89.00	$267.00	None
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG	2	Generic	$15.00	$45.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL	2	Generic	$15.00	$45.00	None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL	2	Generic	$15.00	$45.00	None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE	4	Non-Preferred Brand	$89.00	$267.00	None
METRONIDAZOLE VAGINAL GEL	3	Preferred Brand	$38.00	$114.00	None
MEXILETINE 150MG CAPSULE	4	Non-Preferred Brand	$89.00	$267.00	None
MEXILETINE 200MG CAPSULE	4	Non-Preferred Brand	$89.00	$267.00	None
MEXILETINE 250MG CAPSULE	4	Non-Preferred Brand	$89.00	$267.00	None
MIACALCIN 400 UNIT/2 ML VIAL	5	Specialty Tier	33%	N/A	P
MICROGESTIN 21 1-20 TABLET	3	Preferred Brand	$38.00	$114.00	None
MICROGESTIN 21 1.5-30 TAB	3	Preferred Brand	$38.00	$114.00	None
MICROGESTIN FE 1-20 TABLET	2	Generic	$15.00	$45.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MICROGESTIN FE 1.5-30 TAB	3	Preferred Brand	$38.00	$114.00	None
MIDODRINE HCL 10MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
MIDODRINE HCL 2.5MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	None
MIDODRINE HCL 5MG TABLET (100 CT)	4	Non-Preferred Brand	$89.00	$267.00	None
MINITRAN 0.1 MG/HR PATCH	3	Preferred Brand	$38.00	$114.00	None
MINITRAN 0.2 MG/HR PATCH	3	Preferred Brand	$38.00	$114.00	None
MINITRAN 0.4 MG/HR PATCH	3	Preferred Brand	$38.00	$114.00	None
MINITRAN 0.6 MG/HR PATCH	3	Preferred Brand	$38.00	$114.00	None
MINOCYCLINE 50MG CAPSULE	2	Generic	$15.00	$45.00	None
MINOCYCLINE HCL 75MG CAPSULE	2	Generic	$15.00	$45.00	None
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC	2	Generic	$15.00	$45.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MINOXIDIL 10MG TABLET	2	Generic	$15.00	$45.00	None
MINOXIDIL 2.5MG TABLET	2	Generic	$15.00	$45.00	None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE	3	Preferred Brand	$38.00	$114.00	Q:30 /30Days
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE	2	Generic	$15.00	$45.00	Q:45 /30Days
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE	3	Preferred Brand	$38.00	$114.00	None
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE	2	Generic	$15.00	$45.00	None
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE	2	Generic	$15.00	$45.00	Q:45 /30Days
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX	3	Preferred Brand	$38.00	$114.00	None
MIRTAZAPINE TABLET 30MG (30 CT)	2	Generic	$15.00	$45.00	None
misoprostol 100 mcg tablet	3	Preferred Brand	$38.00	$114.00	None
misoprostol 200 mcg tablet	3	Preferred Brand	$38.00	$114.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MITOMYCIN 20 MG VIAL	4	Non-Preferred Brand	$89.00	$267.00	P
MITOXANTRONE INJECTION 2MG 125ML VIAL	3	Preferred Brand	$38.00	$114.00	P
Moderiba 200 mg tablet	3	Preferred Brand	$38.00	$114.00	None
Moderiba 400-400 mg dosepack	5	Specialty Tier	33%	N/A	None
Moderiba 600-600 mg dosepack	5	Specialty Tier	33%	N/A	None
Moexipril hcl 15 mg tablet	1	Preferred Generic	$4.00	$12.00	None
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$4.00	$12.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET	1	Preferred Generic	$4.00	$12.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET	1	Preferred Generic	$4.00	$12.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET	1	Preferred Generic	$4.00	$12.00	None
MOLINDONE HCL 10 MG TABLET [Moban]	4	Non-Preferred Brand	$89.00	$267.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MOLINDONE HCL 25 MG TABLET [Moban]	4	Non-Preferred Brand	$89.00	$267.00	None
MOLINDONE HCL 5 MG TABLET [Moban]	4	Non-Preferred Brand	$89.00	$267.00	None
MOMETASONE FUROATE 0.1% CREAM	3	Preferred Brand	$38.00	$114.00	None
MOMETASONE FUROATE 0.1% OINT	3	Preferred Brand	$38.00	$114.00	None
MOMETASONE FUROATE 0.1% SOLN	3	Preferred Brand	$38.00	$114.00	None
MOMETASONE FUROATE 50 MCG SPRY	3	Preferred Brand	$38.00	$114.00	Q:34 /30Days
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN	3	Preferred Brand	$38.00	$114.00	None
MONTELUKAST SOD 10 MG TABLET [Singulair]	3	Preferred Brand	$38.00	$114.00	None
montelukast sod 4 mg granules [Singulair]	4	Non-Preferred Brand	$89.00	$267.00	None
montelukast sod 4 mg tab chew [Singulair]	3	Preferred Brand	$38.00	$114.00	None
montelukast sod 5 mg tab chew [Singulair]	3	Preferred Brand	$38.00	$114.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MORPHINE 10 MG/ML ISECURE SYR	3	Preferred Brand	$38.00	$114.00	P
Morphine 2 mg/ml isecure syr	3	Preferred Brand	$38.00	$114.00	P
Morphine 4 mg/ml isecure syr	3	Preferred Brand	$38.00	$114.00	P
MORPHINE 8 MG/ML ISECURE SYR	3	Preferred Brand	$38.00	$114.00	P
MORPHINE SULFATE 100MG TABLET SA	4	Non-Preferred Brand	$89.00	$267.00	Q:90 /30Days
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE	3	Preferred Brand	$38.00	$114.00	None
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION	3	Preferred Brand	$38.00	$114.00	None
MORPHINE SULFATE 15MG TABLET SA	4	Non-Preferred Brand	$89.00	$267.00	Q:90 /30Days
MORPHINE SULFATE 15MG TABLETS	3	Preferred Brand	$38.00	$114.00	Q:180 /30Days
MORPHINE SULFATE 200MG TABLET SA	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION	3	Preferred Brand	$38.00	$114.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MORPHINE SULFATE 30MG TABLET SA	4	Non-Preferred Brand	$89.00	$267.00	Q:90 /30Days
MORPHINE SULFATE 30MG TABLETS	3	Preferred Brand	$38.00	$114.00	Q:180 /30Days
MORPHINE SULFATE ER 10 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 100 MG CAP	5	Specialty Tier	33%	N/A	Q:60 /30Days
MORPHINE SULFATE ER 120 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 20 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 30 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 30 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 45 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 50 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 60 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MORPHINE SULFATE ER 60 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 75 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE ER 80 MG CAP	5	Specialty Tier	33%	N/A	Q:60 /30Days
MORPHINE SULFATE ER 90 MG CAP	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MORPHINE SULFATE TABLET ER 60MG (100 CT)	4	Non-Preferred Brand	$89.00	$267.00	Q:90 /30Days
MOVANTIK 12.5 MG TABLET	3	Preferred Brand	$38.00	$114.00	Q:60 /30Days
MOVANTIK 25 MG TABLET	3	Preferred Brand	$38.00	$114.00	Q:30 /30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET	4	Non-Preferred Brand	$89.00	$267.00	None
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE	3	Preferred Brand	$38.00	$114.00	None
MOZOBIL 20 MG/ML VIAL	5	Specialty Tier	33%	N/A	P
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	$89.00	$267.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MUPIROCIN 2% OINTMENT	2	Generic	$15.00	$45.00	None
MUSTARGEN 10 MG VIAL	4	Non-Preferred Brand	$89.00	$267.00	P
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION	5	Specialty Tier	33%	N/A	None
MYCAMINE 50MG VIAL	5	Specialty Tier	33%	N/A	None
MYCOPHENOLATE 200 MG/ML SUSP	5	Specialty Tier	33%	N/A	P
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK	4	Non-Preferred Brand	$89.00	$267.00	P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT	4	Non-Preferred Brand	$89.00	$267.00	P
Mycophenolic Acid DR 180 mg tb	4	Non-Preferred Brand	$89.00	$267.00	P
Mycophenolic Acid DR 360 mg tb	5	Specialty Tier	33%	N/A	P
MYORISAN 10 MG CAPSULE	4	Non-Preferred Brand	$89.00	$267.00	None
MYORISAN 20 MG CAPSULE	4	Non-Preferred Brand	$89.00	$267.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Myorisan 30 mg capsule	4	Non-Preferred Brand	$89.00	$267.00	None
MYORISAN 40 MG CAPSULE	4	Non-Preferred Brand	$89.00	$267.00	None
MYRBETRIQ ER 25 MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	Q:60 /30Days
MYRBETRIQ ER 50 MG TABLET	4	Non-Preferred Brand	$89.00	$267.00	Q:30 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D SecureRx - Option 3 (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.