2017 Medicare Part D Plan Formulary Information |
Apollo @ Home- Constellation Health (HMO) (H8266-004-0)
Benefit Details
|
The Apollo @ Home- Constellation Health (HMO) (H8266-004-0) Formulary Drugs Starting with the Letter M in TOA ALTA County, PR: CMS MA Region 30 which includes: PR 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 |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Macrobid 25; 75mg/1; mg/1 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Macrodantin Nitrofurantion crystals 100mg 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Macrodantin Nitrofurantion crystals 25mg 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Macrodantin Nitrofurantion crystals 50mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Magnesium sulfate 50% vial |
1 |
Generic |
$5.00 | N/A | P |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
Generic |
$5.00 | N/A | P |
MALARONE 250-100MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MALARONE 62.5-25MG PED TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAPROTILINE 25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAPROTILINE 50MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAPROTILINE 75MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Marinol 10mg/1 60 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
MARINOL 2.5MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
MARINOL 5MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
MARLISSA-28 TABLET |
1 |
Generic |
$5.00 | N/A | None |
MARPLAN 10MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MATULANE 50MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
MAXALT 10mg/1 18 POUCH per CARTON / 1 TABLET in 1 POUCH |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXALT 5mg/1 18 POUCH per CARTON / 1 TABLET in 1 POUCH |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXALT MLT 10 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT MLT 5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXIPIME 1 GRAM VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXIPIME 2 GRAM VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXITROL EYE OINTMENT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXITROL SUS 0.1% OP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXZIDE 37.5 MG-25 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MAXZIDE 50; 75mg 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MECLIZINE 12.5 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MECLIZINE 25 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MEDROL 16MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MEDROL 2 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROL 32MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MEDROL 4MG DOSEPAK |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MEDROL 4MG DOSEPAK (100 CT) |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MEDROL 8MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MEDROXYPROGESTERONE 150 MG/ML |
1 |
Generic |
$5.00 | N/A | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Generic |
$5.00 | N/A | None |
MEGACE 40MG/ML ORAL SUSP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MEGESTROL 20MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Generic |
$5.00 | N/A | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | N/A | None |
MEKINIST 0.5 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
MEKINIST 2 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
Meloxicam 15 mg tablet |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Meloxicam 7.5 mg tablet |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
1 |
Generic |
$5.00 | N/A | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
1 |
Generic |
$5.00 | N/A | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
1 |
Generic |
$5.00 | N/A | None |
MEMANTINE HCL 5 MG TABLET [Namenda] |
1 |
Generic |
$5.00 | N/A | 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 |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.3MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MENEST 0.625MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MENEST 1.25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MENHIBRIX VACCINE VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MENVEO A-C-Y-W-135-DIP VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Meperidine Hydrochloride 100mg/mL 25 VIAL per CARTON / 1 mL in 1 VIAL |
1 |
Generic |
$5.00 | N/A | P |
Meperidine Hydrochloride 25mg/mL 25 VIAL per CARTON / 1 mL in 1 VIAL |
1 |
Generic |
$5.00 | N/A | P |
Meperidine Hydrochloride 50mg/mL 25 VIAL per CARTON / 1 mL in 1 VIAL |
1 |
Generic |
$5.00 | N/A | P |
MEPROBAMATE 200 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MEPROBAMATE 400 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MEPRON 750MG/5ML ORAL SUSP |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MERCAPTOPURINE 50MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
1 |
Generic |
$5.00 | N/A | P |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Mesalamine 1 KIT per CARTON |
1 |
Generic |
$5.00 | N/A | None |
MESALAMINE 800 MG DR TABLET |
1 |
Generic |
$5.00 | N/A | None |
Mesna 100 mg/ml vial |
1 |
Generic |
$5.00 | N/A | P |
MESNEX 100MG/ML INJECTION |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
MESNEX 400MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MESTINON 180MG TIMESPAN |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MESTINON 60MG/5ML SYRUP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MESTINON TABLETS 60MG 100 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAXALONE 800 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
Metformin hcl 500 mg tablet |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METFORMIN HCL ER 500 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:120 /30Days |
Metformin Hydrochloride 750mg/1 |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METHAZOLAMIDE 25MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Methenamine Hippurate 1g/1 |
1 |
Generic |
$5.00 | N/A | None |
METHIMAZOLE 10 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METHIMAZOLE 5MG TABLETS |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methocarbamol 500mg 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Generic |
$5.00 | N/A | None |
methotrexate 1 gm vial |
1 |
Generic |
$5.00 | N/A | P |
METHOTREXATE 2.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Methotrexate 25 mg/ml vial |
1 |
Generic |
$5.00 | N/A | P |
Methotrexate 50 mg/2 ml vial |
1 |
Generic |
$5.00 | N/A | P |
Methoxsalen 10 mg Capsule [8-MOP] |
1 |
Generic |
$5.00 | N/A | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
METHYLDOPA 250MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Methyldopa 500mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE 10MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 10mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
Methylprednisolone 125 mg vial |
1 |
Generic |
$5.00 | N/A | P |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
1 |
Generic |
$5.00 | N/A | None |
methylprednisolone 40 mg vial |
1 |
Generic |
$5.00 | N/A | P |
Methylprednisolone 40 mg/ml vl |
1 |
Generic |
$5.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Generic |
$5.00 | N/A | None |
Methylprednisolone 80 mg/ml vl |
1 |
Generic |
$5.00 | N/A | P |
Metipranolol 0.3% eye drops |
1 |
Generic |
$5.00 | N/A | None |
Metoclopramide 10mg/1 |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Metoclopramide 5 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
1 |
Generic |
$5.00 | N/A | None |
Metoclopramide 5mg |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
METOLAZONE 10MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 2.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METOLAZONE 5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
METOPROLOL SUCCINATE ER 200 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
METOPROLOL TARTRATE 100 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
METROCREAM 0.75% CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
METROGEL-VAGINAL 0.75% GEL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
METROLOTION TOPICAL 0.75% |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Generic |
$5.00 | N/A | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Generic |
$5.00 | N/A | None |
metronidazole 375 mg capsule |
1 |
Generic |
$5.00 | N/A | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
1 |
Generic |
$5.00 | N/A | P |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Generic |
$5.00 | N/A | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Generic |
$5.00 | N/A | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE VAGINAL GEL |
1 |
Generic |
$5.00 | N/A | None |
MEXILETINE 150MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
MEXILETINE 200MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
MEXILETINE 250MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
MIACALCIN 400 UNIT/2 ML VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Microgestin 21 1-20 tablet |
1 |
Generic |
$5.00 | N/A | None |
MICROGESTIN 21 1.5-30 TAB |
1 |
Generic |
$5.00 | N/A | None |
Microgestin fe 1-20 tablet |
1 |
Generic |
$5.00 | N/A | None |
MICROGESTIN FE 1.5-30 TAB |
1 |
Generic |
$5.00 | N/A | None |
MICROZIDE 12.5MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MIDODRINE HCL 10MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 2.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
Miglitol 100 MG TABLET [Glyset] |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
Miglitol 25 MG TABLET [Glyset] |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
Miglitol 50 MG TABLET [Glyset] |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Millipred 5 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
MINIPRESS 1MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Minipress 2mg/1 250 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Minipress 5mg/1 250 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MINOCIN 100 MG PELLETIZED CAP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCIN 50 MG PELLETIZED CAP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
MINOCYCLINE 75 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
Minocycline Hydrochloride 100mg/1 50 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | N/A | None |
MINOXIDIL 10MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MINOXIDIL 2.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MIRAPEX 0.125MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MIRAPEX 0.25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MIRAPEX 0.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MIRAPEX 0.75MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MIRAPEX 1.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRAPEX 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Mirtazapine 15 mg odt |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Mirtazapine 15mg/1 1000 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
MIRTAZAPINE 30 MG ODT |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Mirtazapine 45 mg odt |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Mirtazapine 7.5mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
MIRVASO TOP GEL 0.33% |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
misoprostol 100 mcg tablet |
1 |
Generic |
$5.00 | N/A | None |
misoprostol 200 mcg tablet |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
Generic |
$5.00 | N/A | P |
MOBIC 15MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
MOBIC 7.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Modafinil 100 mg tablet [Provigil] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Modafinil 200 mg tablet [Provigil] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Moexipril hcl 15 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
MOMETASONE FUROATE 0.1% CREAM |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOMETASONE FUROATE 0.1% OINT |
1 |
Generic |
$5.00 | N/A | None |
MOMETASONE FUROATE 0.1% SOLN |
1 |
Generic |
$5.00 | N/A | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
1 |
Generic |
$5.00 | N/A | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
montelukast sod 4 mg granules [Singulair] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Montelukast sod 4 mg tab chew [Singulair] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Montelukast sod 5 mg tab chew [Singulair] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
MORPHINE SULFATE 10 mg/5 ml soln |
1 |
Generic |
$5.00 | N/A | None |
MORPHINE SULFATE 100 mg/5 ml soln |
1 |
Generic |
$5.00 | N/A | None |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 15MG TABLETS |
1 |
Generic |
$5.00 | N/A | Q:120 /30Days |
MORPHINE SULFATE 20 mg/5 ml soln |
1 |
Generic |
$5.00 | N/A | None |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
MORPHINE SULFATE 30MG TABLETS |
1 |
Generic |
$5.00 | N/A | Q:120 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
1 |
Generic |
$5.00 | N/A | None |
MOZOBIL 20 MG/ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
MS CONTIN 100 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
MS CONTIN 15 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MS CONTIN 200 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
MS CONTIN 30 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
MS CONTIN 60 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
mupirocin 2% cream |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MUPIROCIN 2% OINTMENT |
1 |
Generic |
$5.00 | N/A | None |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
4 |
Specialty Tier |
33% | N/A | P |
MYAMBUTOL 400 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
4 |
Specialty Tier |
33% | N/A | P |
MYCAMINE 50MG VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
MYCOBUTIN 150MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLATE 200 MG/ML SUSP |
1 |
Generic |
$5.00 | N/A | P |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Generic |
$5.00 | N/A | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Generic |
$5.00 | N/A | P |
Mycophenolic Acid DR 180 mg tb |
1 |
Generic |
$5.00 | N/A | P |
Mycophenolic Acid DR 360 mg tb |
1 |
Generic |
$5.00 | N/A | P |
MYFORTIC 180MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
MYFORTIC 360MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
MYORISAN 10 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
MYORISAN 20 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
Myorisan 30 mg capsule |
1 |
Generic |
$5.00 | N/A | None |
MYORISAN 40 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYRBETRIQ ER 25 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
MYRBETRIQ ER 50 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Mysoline 50mg/1 |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
MYTESI 125 MG DR TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |