2017 Medicare Part D Plan Formulary Information |
Health Net Jade Cardiovascular (HMO SNP) (H0351-042-0)
Benefit Details
|
The Health Net Jade Cardiovascular (HMO SNP) (H0351-042-0) Formulary Drugs Starting with the Letter M in Pinal County, AZ: CMS MA Region 21 which includes: AZ Plan Monthly Premium: $0.00 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 |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Magnesium sulfate 50% vial |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MALARONE 62.5-25MG PED TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MALATHION 0.5% LOTION |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MAPROTILINE 25MG TABLET |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
MAPROTILINE 50MG TABLET |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
Marinol 10mg/1 60 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
MARINOL 5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARLISSA-28 TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MATULANE 50MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
Matzim LA 180mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Matzim LA 300mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Matzim LA 360mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Matzim LA 420mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MECLIZINE 12.5 MG TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
MECLIZINE 25 MG TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROL 2 MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MEDROXYPROGESTERONE 150 MG/ML |
2 |
Generic |
$15.00 | $42.00 | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
MEFENAMIC ACID 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MEGESTROL 20MG TABLET |
2 |
Generic |
$15.00 | $42.00 | P |
MEGESTROL 625 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $42.00 | P |
Megestrol Acetate 125 MG/ML Oral Suspension [Megace] |
5 |
Specialty Tier |
33% | 33% | P |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Generic |
$15.00 | $42.00 | 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 |
3 |
Preferred Brand |
$37.00 | $101.00 | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Meloxicam 15 mg tablet |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Meloxicam 7.5 mg tablet |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
2 |
Generic |
$15.00 | $42.00 | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
2 |
Generic |
$15.00 | $42.00 | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
2 |
Generic |
$15.00 | $42.00 | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Generic |
$15.00 | $42.00 | P |
MEMANTINE HCL 5 MG TABLET [Namenda] |
2 |
Generic |
$15.00 | $42.00 | 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 |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENHIBRIX VACCINE VIAL |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MENOSTAR 14 MCG/DAY PATCH |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MENVEO A-C-Y-W-135-DIP VIAL |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MEPERIDINE 100 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P Q:20 /1Days |
Meperidine Hydrochloride 50 MG Oral Tablet [Demerol] |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P Q:40 /1Days |
MEPROBAMATE 200 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MEPROBAMATE 400 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MEPRON 750MG/5ML ORAL SUSP |
5 |
Specialty Tier |
33% | 33% | None |
MERCAPTOPURINE 50MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Mesalamine 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESALAMINE 800 MG DR TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Mesna 100 mg/ml vial |
2 |
Generic |
$15.00 | $42.00 | None |
MESNEX 100MG/ML INJECTION |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Metadate er 20 mg tablet |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Metaxall 800 mg tablet |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
Metaxalone 400 MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | P |
METAXALONE 800 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
METFORMIN ER 1,000 MG OSM-TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
METFORMIN HCL 1,000 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Metformin hcl 500 mg tablet |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL ER 500 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Metformin Hydrochloride 750mg/1 |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
METHADONE HCL 5MG TABLET (100 CT) |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:13 /1Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:7 /1Days |
Methadone Hydrochloride 10mg/5mL |
2 |
Generic |
$15.00 | $42.00 | Q:33 /1Days |
Methadone Hydrochloride 5mg/5mL |
2 |
Generic |
$15.00 | $42.00 | Q:67 /1Days |
METHAMPHETAMINE HYDROCHLORIDE TABLETS 5 MG |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
METHAZOLAMIDE 25MG TABLET |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Methenamine Hippurate 1g/1 |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHIMAZOLE 10 MG TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
METHIMAZOLE 5MG TABLETS |
2 |
Generic |
$15.00 | $42.00 | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $42.00 | P |
METHOCARBAMOL 750MG TABLET (500 CT) |
2 |
Generic |
$15.00 | $42.00 | P |
Methotrexate 0.55 ML 50 MG/ML Auto-Injector [Rasuvo] |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
methotrexate 1 gm vial |
2 |
Generic |
$15.00 | $42.00 | None |
METHOTREXATE 2.5MG TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
Methotrexate 25 mg/ml vial |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Methotrexate 50 mg/2 ml vial |
2 |
Generic |
$15.00 | $42.00 | None |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
33% | 33% | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METHYLDOPA 250MG TABLET |
2 |
Generic |
$15.00 | $42.00 | P |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $42.00 | P |
METHYLPHENIDATE 10MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPHENIDATE 20MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPHENIDATE CD 10 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METHYLPHENIDATE CD 30 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
methylphenidate cd 50 mg cap |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
methylphenidate cd 60 mg cap |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METHYLPHENIDATE ER 18 MG TAB |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Methylphenidate er 20 mg cap |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylphenidate er 20 mg cap |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METHYLPHENIDATE ER 27 MG TAB |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPHENIDATE ER 36 MG TAB |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Methylphenidate er 40 mg cap |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Methylphenidate er 40 mg cap |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METHYLPHENIDATE ER 54 MG TAB |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Methylphenidate la 60 mg cap |
2 |
Generic |
$15.00 | $42.00 | None |
Methylprednisolone 125 mg vial |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 16MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2 |
Generic |
$15.00 | $42.00 | None |
methylprednisolone 40 mg vial |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Methylprednisolone 40 mg/ml vl |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Methylprednisolone 80 mg/ml vl |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
METHYLTESTOSTERONE 10 MG CAP |
2 |
Generic |
$15.00 | $42.00 | None |
Metipranolol 0.3% eye drops |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metoclopramide 5 mg tablet |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Generic |
$15.00 | $42.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
2 |
Generic |
$15.00 | $42.00 | None |
METOLAZONE 10MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METOLAZONE 2.5MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METOLAZONE 5MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Generic |
$15.00 | $42.00 | None |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Generic |
$15.00 | $42.00 | None |
METOPROLOL SUCCINATE ER 200 MG TAB |
2 |
Generic |
$15.00 | $42.00 | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
2 |
Generic |
$15.00 | $42.00 | None |
METOPROLOL TARTRATE 100 MG TAB |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
METRONIDAZOLE 0.75% CREAM |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METRONIDAZOLE 0.75% LOTION |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
metronidazole 375 mg capsule |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
2 |
Generic |
$15.00 | $42.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2 |
Generic |
$15.00 | $42.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2 |
Generic |
$15.00 | $42.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
metronidazole topical 1% gel |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
METRONIDAZOLE VAGINAL GEL |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MEXILETINE 150MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MEXILETINE 200MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MEXILETINE 250MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MIACALCIN 400 UNIT/2 ML VIAL |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MIBELAS 24 Fe chewable tablet |
2 |
Generic |
$15.00 | $42.00 | None |
Microgestin 21 1-20 tablet |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
MICROGESTIN 21 1.5-30 TAB |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Microgestin fe 1-20 tablet |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN FE 1.5-30 TAB |
1 |
Preferred Generic |
$5.00 | $12.00 | None |
MIDODRINE HCL 10MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MIDODRINE HCL 2.5MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Migergot suppository |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Miglitol 100 MG TABLET [Glyset] |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:3 /1Days |
Miglitol 25 MG TABLET [Glyset] |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:3 /1Days |
Miglitol 50 MG TABLET [Glyset] |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:3 /1Days |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
5 |
Specialty Tier |
33% | 33% | None |
Millipred 5 mg tablet |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | 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 |
$90.00 | $260.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mimvey lo 0.5-0.1 mg tablet |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MINASTRIN 24 FE CHEWABLE TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MINITRAN 0.1 MG/HR PATCH |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MINITRAN 0.2 MG/HR PATCH |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MINITRAN 0.4 MG/HR PATCH |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MINITRAN 0.6 MG/HR PATCH |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MINOCYCLINE 50MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MINOCYCLINE 75 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | 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 | $42.00 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Generic |
$15.00 | $42.00 | None |
MIRAPEX ER 3.75mg/1 ER 30 TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MIRCERA 100 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MIRCERA 200 MCG/0.3 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
MIRCERA 50 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MIRCERA 75 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
Mirtazapine 15 mg odt |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $42.00 | None |
MIRTAZAPINE 30 MG ODT |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Mirtazapine 45 mg odt |
3 |
Preferred Brand |
$37.00 | $101.00 | 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 |
Generic |
$15.00 | $42.00 | None |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $42.00 | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
2 |
Generic |
$15.00 | $42.00 | None |
MIRVASO TOP GEL 0.33% |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
misoprostol 100 mcg tablet |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
misoprostol 200 mcg tablet |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MITIGARE 0.6 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MITOMYCIN 20 MG VIAL |
2 |
Generic |
$15.00 | $42.00 | None |
MITOMYCIN 40 MG VIAL |
2 |
Generic |
$15.00 | $42.00 | None |
MITOMYCIN 5 MG VIAL |
2 |
Generic |
$15.00 | $42.00 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Generic |
$15.00 | $42.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Modafinil 100 mg tablet [Provigil] |
2 |
Generic |
$15.00 | $42.00 | P |
Modafinil 200 mg tablet [Provigil] |
2 |
Generic |
$15.00 | $42.00 | P |
Moderiba 200 mg tablet |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Moderiba 400-400 mg dosepack |
2 |
Generic |
$15.00 | $42.00 | None |
Moderiba 600-600 mg dosepack |
2 |
Generic |
$15.00 | $42.00 | None |
Moexipril hcl 15 mg tablet |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
MOMETASONE FUROATE 0.1% CREAM |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOMETASONE FUROATE 0.1% OINT |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MOMETASONE FUROATE 0.1% SOLN |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MOMETASONE FUROATE 50 MCG SPRY |
2 |
Generic |
$15.00 | $42.00 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Generic |
$15.00 | $42.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:1 /1Days |
Montelukast sod 4 mg tab chew [Singulair] |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:1 /1Days |
Montelukast sod 5 mg tab chew [Singulair] |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:1 /1Days |
MONUROL 3 GM SACHET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MORGIDOX 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MORPHINE SULFATE 10 mg/5 ml soln |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:100 /1Days |
MORPHINE SULFATE 100 mg/5 ml soln |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:10 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 100MG TABLET SA |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:2 /1Days |
MORPHINE SULFATE 15MG TABLET SA |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:13 /1Days |
MORPHINE SULFATE 20 mg/5 ml soln |
3 |
Preferred Brand |
$37.00 | $101.00 | Q:50 /1Days |
MORPHINE SULFATE 200MG TABLET SA |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:2 /1Days |
MORPHINE SULFATE 30MG TABLET SA |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:7 /1Days |
MORPHINE SULFATE ER 10 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:20 /1Days |
MORPHINE SULFATE ER 100 MG CAP |
5 |
Specialty Tier |
33% | 33% | Q:2 /1Days |
MORPHINE SULFATE ER 120 MG CAP |
2 |
Generic |
$15.00 | $42.00 | Q:2 /1Days |
MORPHINE SULFATE ER 20 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:10 /1Days |
MORPHINE SULFATE ER 30 MG CAP |
2 |
Generic |
$15.00 | $42.00 | Q:7 /1Days |
MORPHINE SULFATE ER 30 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:7 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 45 MG CAP |
2 |
Generic |
$15.00 | $42.00 | Q:4 /1Days |
MORPHINE SULFATE ER 50 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:4 /1Days |
MORPHINE SULFATE ER 60 MG CAP |
2 |
Generic |
$15.00 | $42.00 | Q:3 /1Days |
MORPHINE SULFATE ER 60 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:3 /1Days |
MORPHINE SULFATE ER 75 MG CAP |
2 |
Generic |
$15.00 | $42.00 | Q:3 /1Days |
MORPHINE SULFATE ER 80 MG CAP |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:3 /1Days |
MORPHINE SULFATE ER 90 MG CAP |
2 |
Generic |
$15.00 | $42.00 | Q:2 /1Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | Q:3 /1Days |
MOVANTIK 12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MOVANTIK 25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MOZOBIL 20 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$37.00 | $101.00 | None |
mupirocin 2% cream |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MUPIROCIN 2% OINTMENT |
2 |
Generic |
$15.00 | $42.00 | None |
MUSTARGEN 10 MG VIAL |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
5 |
Specialty Tier |
33% | 33% | None |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
33% | 33% | P |
Mycophenolate 500 mg vial |
2 |
Generic |
$15.00 | $42.00 | P |
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 |
$37.00 | $101.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
3 |
Preferred Brand |
$37.00 | $101.00 | P |
Mycophenolic Acid DR 180 mg tb |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
Mycophenolic Acid DR 360 mg tb |
2 |
Generic |
$15.00 | $42.00 | P |
MYFORTIC 180MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P |
MYFORTIC 360MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
MYORISAN 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MYORISAN 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Myorisan 30 mg capsule |
2 |
Generic |
$15.00 | $42.00 | None |
MYORISAN 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
Mysoline 50mg/1 |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None |
MYTESI 125 MG DR TABLET |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P Q:2 /1Days |